Dr Anne Holdoway stresses why preventing malnutrition and dehydration among the elderly should be an integral part of patient-centred care.
As we age, our daily intake of food and drink becomes increasingly vital to our overall wellbeing. Yet, biological changes associated with ageing, in conjunction with long-term medical conditions, can directly impact on our ability and desire to eat, drink, absorb and utilise certain essential nutrients predisposing individuals to malnutrition and dehydration. In turn this can exacerbate an existing condition, contribute to other conditions developing and trigger a decline in health that increases the likelihood of a hospital admission, additional care at home or admission to care homes and nursing homes.
In the UK, it is estimated that one in 10 people over 65 are malnourished or at risk of being malnourished, with residents in care and nursing homes being particularly affected at a rate of one in three. Despite the availability of nutritional screening tools and guidance, stretched health and social care systems, the complexity of conditions and the need for ongoing monitoring and the vigilance required to optimise food and fluid intake often means malnutrition and its associated issues are insufficiently addressed. To find out more, Health Europa Quarterly (HEQ) spoke to Dr Anne Holdoway who is a Consultant Dietitian and Chair of the Managing Adult Malnutrition in the Community UK panel which seeks to raise awareness of malnutrition in the community and offers practical resources for both patients and healthcare professionals to better identify, prevent and treat malnutrition.
What key risk factors make elderly people particularly vulnerable to dehydration and malnutrition, and their effects?
Whilst malnutrition and dehydration may arise from a social situation such as loneliness following bereavement, poverty, limited access to shops and limited ability and motivation to prepare nutritious meals especially when it might only be for one person, there are a host of conditions that can interfere with appetite, digestion, absorption and the drive and cues to eat and drink. Often social factors interplay with medical reasons and it is important to understand both which is why increasingly we encourage nutrition and hydration to be considered as part of the holistic and patient-centred approach to care.
Unpicking the causes through understanding the key factors contributing to the risk of malnutrition and dehydration are important in guiding what actions one might take. We encourage those caring for elderly to consider what factors might be interfering with the ability to eat and drink, and indeed there are many. Firstly, biological changes occur as we age that result in a decline in appetite, this has been described as the ‘anorexia of ageing’. The ageing process itself, medical conditions and associated medications can also affect or alter our taste and smell which are important drivers to eat and drink and which can reduce the pleasure and enjoyment we derive from eating and drinking.
Social factors that contribute to malnutrition and dehydration can often be managed through the provision of adequate food and fluid made possible through food banks, assistance at mealtimes, meal clubs, meal delivery and social prescribing activities. In contrast, malnutrition that is associated with disease may be more challenging to deal with because the disease itself may not only interfere with appetite but also result in eating and drinking difficulties, affect the digestion and absorption of the food and drink consumed. In addition, we now know that conditions such as cancer, chronic obstructive respiratory disease, rheumatoid arthritis, Crohn’s disease, and COVID-19, which have an inflammatory component, suppresses appetite, induces early satiety which is the feeling of fullness that can occur prematurely after eating only small amounts of food and is more resistant to dietary interventions. The inflammatory process also contributes to loss of muscle. In an elderly individual it is challenging to regain the muscle once lost so strategies to optimise intake of protein combined with activity or resistance training are playing an increasingly important role in treating malnutrition in vulnerable older people.
The ageing process also reduces synthesis of muscle which increases our likelihood of becoming more frail. Frailty and the risk of falling may further hinder our ability to eat, drink, prepare and shop for food. One can begin to see how an elderly person with medical conditions becomes increasingly frail, increasingly isolated and at increased risk of becoming malnourished and dehydrated.
If that is not enough, many elderly will experience swallowing problems (dysphagia), due to neurological conditions such as Parkinson’s disease or after a stroke but also because as we age, our swallow reflex becomes less efficient and our muscles for swallowing might become weaker. Coughing and choking when eating and drinking are not only signs that dysphagia may be present but without due attention to manage the swallowing difficulties with appropriate texture of food and the possible use of thickened fluids, the risk of a chest infection and subsequent pneumonia becomes a risk. Problems with swallowing may also induce fear of eating and drinking predisposing the individual to greater risk of malnutrition and dehydration. Other oral issues can arise that interfere with eating including dry mouth, this can be a consequence of a medical condition, treatment such as radiotherapy to the head and neck area, or medications. A dry mouth not only suppresses our taste acuity but necessitates greater effort to eat dry foods, often fatigue sets in or the individual loses interest and hence only part of the meal may be eaten.
Poor oral health and ill-fitting dentures can also be a contributing factor to a reduced desire to eat because of the discomfort associated with eating and drinking so it is important to check the mouth for signs of infections such as oral thrush, sores or the state of the teeth.
With reduced activity and in consuming less food and drink the risk of constipation increases. In turn the constipation and associated bloating can also reduce appetite.
In recent years pharmacists have taken on new roles in the community and in care homes to address polypharmacy and optimisation of medicines. In many regions, pharmacists now lead on medication reviews for elderly living independently, those attending frailty clinics along with residents in care homes and nursing homes. Pharmacists can be invaluable in asking first line questions about what a person is eating and drinking as part of their reviews and assess whether medications including those that are interfering with eating and drinking remain of benefit or can be discontinued.
Cognitive difficulties, for instance amongst those with dementia, also risk malnutrition and dehydration as a person may have difficulty expressing their food likes and dislike. Compound this with fear and anxiety associated with being in an unfamiliar environment, less familiar foods being on offer and regular staff changes and one can see how an individual might eat and drink less in a care setting. It is therefore particularly important to make sure that care staff seek to know and understand people’s food and drink preferences to offer food that is desirable.
These examples hopefully illustrate just how many factors play a part in increasing the likelihood of malnutrition and dehydration in our elderly, vulnerable population. You could probably apply a downward cycle to all these issues and see how one problem contributes to another.
What signs of dehydration and malnutrition should carers, clinical staff and family members be particularly aware of?
Whilst malnutrition has been defined as a deficiency of energy, protein and other nutrients that causes adverse effects on the body (shape, size and composition), the way it functions and clinical outcomes, the perfect tool and formal diagnosis has remained an area of debate for several decades. In recent years, considerable progress has been made in identifying the risk or presence of malnutrition through the use of validated screening tools, the outputs of research and multi-professional debate. Even more recently, worldwide collaborations have enabled a move towards a consensus not just on a national basis but an international basis, to create diagnostic criteria for malnutrition and determine the type of malnutrition including simple starvation, cachexia and sarcopenia, the latter which refers to loss of muscle, as opposed to just defining risk. This is an exciting step forward which might lead to more specific targeted treatments.
In response to standards published by those commissioning care such as the National Health Service and Care Quality Commission, the use of tools to screen for malnutrition has been widely adopted in care settings to help determine the risk of an individual being malnourished. In addition to screening tools that use objective measures such as weight, height, body mass index, rate of weight loss and interruptions to oral intake, there are tools that also incorporate subjective measures such as appetite, energy levels, presence of fatigue, observations such as swallowing problems, wasted muscles, wounds and functional capacity. Both tools and assessments rely on the ability of carers to interpret the findings and act on them and should be underpinned by training and education tailored to the staff involved and the organisations in which they work.
For dehydration, blood results can be indicative however in the community tests may be invasive, not readily available or interpreted. Observations and questions that are useful to assess include the presence of thirst, headaches, dry mouth, dry lips, tiredness, feeling dizzy or light-headed, confusion, passing small amounts of dark coloured, concentrated urine and dry sunken eyes and fragile skin.
Whilst the adoption of this range of observations can sound overwhelming, integrating them into everyday observations, encouraging communication between care staff, staff continuity, building relationships with those being cared for and initiating questions on eating and drinking into conversations with clients can identify issues or help trigger alerts to investigate and address problems that are present or developing and facilitate early action.
What techniques can care staff employ to monitor the fluid and food intake of residents and encourage this?
The most common screening tool for detecting malnutrition used in care settings in the UK is the Malnutrition Universal Screening Tool (MUST). This evaluates risk of malnutrition. A score of one indicates a risk of malnutrition and two or above is a sign that someone is very likely to be malnourished. With two thirds of the population now overweight or obese, malnutrition can be masked by a high body mass index. As MUST also considers unplanned weight loss and the rate of loss, this can be a useful indicator of malnutrition in someone with a high body mass. In the elderly, any weight loss also risks loss of muscle, this can have profound effects on function, ability to perform everyday activities, independence, and immunity.
Regardless of risk category, advice on adjusting diet to maximise intake and help slow weight loss and restore or preserve function is key. Those with severe malnutrition are likely to benefit from dietary advice combined with appropriate use of oral nutritional supplements which can be self-purchased or prescribed. Those at high risk or who fail to respond to first line interventions require referral to a registered dietitian for specialist advice on treatment and long-term management of risk.
Based on my own experience over 30 years and the work I undertake in practice and in roles within the British Association for Parenteral and Enteral Nutrition (BAPEN), it is important to highlight that screening is crucial to identify those at risk of malnutrition and should be regularly undertaken as it can develop or worsen at any time, but it is crucial to remember that screening is only the starting point. If someone is identified at risk of malnutrition through use of a screening tool, or is struggling with eating and drinking or reports a poor appetite or unplanned weight loss, monitoring them and assessing their situation to really unpack the reasons as to why they might not be eating so well is necessary to identify early actions needed to preserve function, well-being and avoid unnecessary deterioration. In any care setting, good nutrition and hydration management should be an integral component of holistic care. There are situations where clients will refuse to eat and drink, such situations can be challenging and distressing, especially when communication is difficult due to cognitive or communication issues, in these situations skilled carers who know the individual, are empathetic, supportive, encouraging and provide the necessary assistance to enable the individual to eat and drink as safely as possible are of considerable value. The recently updated guidance from the Royal College of Physicians provides a practical guide on dealing with eating and drinking difficulties especially those toward the end of life.
Many practical tools and approaches have been developed to help carers support those who may be struggling with eating and drinking from both a physical and cognitive perspective. In the area of dementia as an example, using coloured glasses has been shown to increase fluid intake and the same is true for those with poor vision.
Getting to know the likes and dislikes of residents or patients, acknowledging cultural and religious beliefs, can help provide favourite foods and drinks that are more likely to be consumed and enjoyed. As older people can be in care settings for months or years, there may be ample opportunities to determine likes and dislikes. When communication difficulties are present, family members and friends can be a useful source of information regarding food preferences whilst also appreciating that taste and preferences may change.
The presentation of the meal can also increase the enjoyment and intake, offering small, attractive meals and snacks and nourishing drinks throughout the day can help those with poor appetite who cannot consume large quantities at any one sitting and fortifying foods and fluids to make them more nutrient dense can help boost intake without increasing the volume needed to be eaten.
Observing what food and drink is consumed against that to be expected is an important component of ongoing monitoring and its value is not to be underestimated. A food and drink record over a few days can be useful to determine whether an individual’s intake is improving or deteriorating, whether further actions are needed including seeking expert advice from a dietitian.
In care settings, efforts should be made to create a comfortable eating environment through use of lighting, tableware, ventilation, avoiding distractions and encouraging social interactions. Catering staff may benefit from additional training to learn how to fortify foods to make each mouthful more nutritious or create texture modified diets including pureed foods that resemble their solid counterparts and look more attractive and appealing when served. Providing assistance, extra time and feeding aids to those who require them, is crucial. Strategies to mix residents at tables according to ability can also alleviate pressures on staff by placing individuals with preserved physical or cognitive ability with those of lesser ability. If permitted, encouraging family members to participate in meals can also address staff shortages if risks are managed, plus the cost of a meal for a relative is likely easily offset against the release of staff to be able to concentrate on those most needy. Eating in the company of others not only encourages social interactions and can be cognitively stimulating it can also result in an individual consuming more. In care settings there may be some residents who prefer to eat away from others in their own room, this should be respected whilst still providing any assistance needed to support safe eating and drinking.
Time is often presented as a barrier to supporting nutrition and hydration but perhaps we should be thinking more creatively in addressing this issue by engaging older people in preparing the food they eat. Red tape and rigid risk-management often stands in the way of making change, but an army of helpers may be to hand if such barriers can be overcome. Enabling older people to make an active contribution through meal preparation and food-related activities might facilitate and maintain engagement in activities of daily living that ensure that our elders feel connected and valued.
What policies should nursing homes and care facilities put in place to minimise residents’ risk of dehydration and malnutrition?
Policies and guidelines have been in place for the last 20 years which pay heed to the importance of nutrition and hydration as an absolute standard of care and yet malnutrition and dehydration remain a significant problem. Between 2014 and 2017 the Care Quality Commission took approximately 50 enforcement actions against care homes for breaching nutrition and hydration regulations. The standards and guidelines are important, but the ongoing issues suggest that they are insufficient perhaps because of the complexities associated with providing effective nutritional and hydration care which we have explored in this interview. Making a difference in this area is likely to require training and education and there are some great examples where dietitians and nurse specialists have led on initiatives to improve education and training in care homes and residential homes and e-learning specific to identifying malnutrition in care settings has been created by organisations including BAPEN. In addition to training and education, acknowledgement and recognition that nutrition and hydration is perceived as an integral component of care by all those involved, including healthcare staff, catering, carers and volunteers, is important to achieve lasting change and embed nutrition and hydration in everyday care. My experience at a local and national level in a variety of settings has demonstrated that nutrition champions make a difference, that is where someone takes the lead on nutrition and hydration and supports colleagues, carers and volunteers to implement small, sequential positive change to improve nutrition and hydration. The work I have been involved with in Chairing the national panel on ‘Managing Adult Malnutrition in the Community’ seeks to facilitate such champions. Over time we have expanded the range of resources available to include advice and information on screening, self-screening, tips on diet, a pathway to guide the use of oral nutritional supplements and specific information for care homes (www.malnutritionpathway.co.uk). The resources are free to access and seek to support those who do not have access to any local resources. If anyone reading this article would like to know more then please do email us.
Are there any key messages you would like to finish with?
Across the globe and across the lifespan, eating and drinking and the associated pleasure is considered an integral part of everyday life. When caring for our elderly population we should be aware that the risk of malnutrition and hydration is ever present. Early action to alleviate the issues and associated distress, should utilise the tools that are currently available including dietary modifications, texture modified diets, additional nutrition through snacks, nourishing drinks and oral nutritional supplements when indicated, drawing on the expertise of others including dietitians and nurse specialists when needed. The value of good nutrition and hydration is not to be underestimated – getting nutrition and hydration right, whether it is for those in a care setting or for individuals living independently, not only reduces the adverse effects of malnutrition and dehydration at an individual and organisational level but enables us to positively enhance the care we provide to the elders in our society.
Dr Anne Holdoway DHealth BSc RD FBDA
Chair of ‘Managing Adult Malnutrition in the Community’ expert panel
Fellow of the British Dietetic Association
BAPEN Education Officer