Thinking of malnutrition tends to generate images of starving people in third world countries. But malnutrition is silently affecting aging people at home. It afflicts a third of older adults admitted to hospital and over half of aged care residents – and it is often overlooked.
Malnutrition in aging can have serious consequences for physical and mental health, recovery from illness and quality of life. Prevention is best, so it is important to detect malnutrition early.
How can you tell if your loved one – whether it be partner, parent, grandparent or someone you care for – is malnourished or at risk for malnutrition? Here are some clues to be aware of.
The primary, most obvious symptom is weight loss. Technically malnutrition is defined as unintentionally losing 5-10% body weight over 3-6 months. Other indicators include baggy clothes and belts. Even loose jewellery (e.g. rings) and dentures are tell-tale signs.
Food provides calories and essential nutrients needed to produce energy. Not meeting nutritional needs through diet can result in tiredness, weakness and dizziness. A clue here could be reduced levels of mobility. Look out for diminished muscle mass – a risk factor for sarcopenia.
It’s commonly recognised that depression can affect people’s appetite. But nutrients from food – carbohydrates, protein, healthy fats, vitamins and minerals – are also vital for healthy brain function. Not getting enough can impact mood and even lead to major depression.
Aging and some medications can alter taste and appetite. Eating less can, in turn, reduce appetite. Strategies to provide tasty, nutrient-rich food, small meals and regular snacks can help mitigate this.
You can’t fool your dentist. Teeth and gums are a key indicator of nutrition and health status. Swollen or bleeding gums are early oral symptoms of malnutrition. If malnutrition progresses, it can cause irreversible tooth decay.
Check brushes and clothes for excess hair. Hair loss and lack lustre hair can reflect poor nutrition status, particularly insufficient protein and iron. Nails also become dry, brittle and discoloured if essential nutrients are lacking. When iron levels drop too low, nails can start curling upwards, signalling possible iron-deficiency anaemia.
Our immune system needs nutrients to prevent and ward off disease. Frequent illness and infections can reveal poor nutrition status. Also be on the watch for easy bruising and wounds that don’t heal easily.
Chronic constipation can signal insufficient food intake to mobilise the digestive tract; it can also reflect inadequate fibre and/or dehydration – common in older adults. Conversely, watch out for persistent diarrhoea because this can decrease nutrient absorption and exacerbate malnutrition.
Several strategies can prevent and alleviate malnutrition. Most important are regular meals and snacks containing protein and energy, a variety of food from the key food groups, and regular drinks to avoid dehydration.
Barriers and catalysts of eating need to be identified and addressed, and every effort made to help older people enjoy food and the enhanced wellbeing that it delivers.
As we face a burgeoning aging population, food quality in aged care has entered the limelight. After all, nutrition is pivotal for good health and healthy aging. Food also enhances quality of life through the joy of eating and the social interaction that it fosters.
Yet more than half of Australian aged care residents suffer or are at risk for malnutrition.
Malnutrition carries a host of negative outcomes like increased risk of falls, osteoporosis, arthritis, poor recovery from illness, delayed wound healing, depression and mortality. It lowers quality of life. And it is preventable.
It’s not just a matter of ensuring all nutritional needs are met, which include protein, energy and a variety of foods from each food group. Several other considerations factor in.
Improving older people’s nutrition status would need a multifactorial approach to address problems with swallowing, dentition, food packaging, eating support, appetite, food preferences, taste and environment.
Fundamentally, quality food needs higher priority in aged care budgets.
Even though people and organisations like Maggie Beer, Nutrition Australia, The Lantern Project and others are tackling this issue, systemic change may only come with mandatory guidelines.
Services provided at residential aged care facilities are regulated under the Aged Care Act, through the Aged Care Standards and Accreditation Agency. The standards include general nutrition information, but no mandatory guidelines for nutrition and menu planning. Hospitals have standards, so why doesn’t aged care?
To rectify this situation, mandatory nutrition standards would need to be created, implemented and enforced for all Australian aged care facilities.
The new standards could contain the following recommendations:
The residential aged care landscape is fragmented. Cooperation among all stakeholders would be imperative for the successful creation, acceptance, adoption, rollout and continuation of new mandatory standards.
Stakeholders include the government’s Australian Aged Care Quality Agency, My Aged Care program, Residential Aged Care Facilities (RACFs), Leading Aged Services Australia, Dietitians Association of Australia, and Speech Pathology Australia.
Challenges would need to be ironed out. Thousands of aged care workers complain about cost cutting, understaffing and rationing in RACFs, resulting in “struggle to provide the most basic level of care and dignity for elderly people.”
Clearly, a cultural overhaul in aged care facilities would be essential for a new mandatory policy to succeed. This could be achieved through collaboration with stakeholders, priority budgeting, and a directive issued from above: the government body responsible for aged care quality.
Everyone becomes more forgetful with age. People start misplacing their keys and worry that they’re losing their marbles. But that’s quite normal. When you forget what to use your keys for, that’s when you might consider a dementia test.
Seventy per cent of people suffering dementia have Alzheimer’s disease, the second major cause of death in Australians. Most common in older age, dementia affects three in ten people over 85 years old. It destroys neurons, causing brain shrinkage and declines in memory, thinking, emotional control and behaviour.
Slipping into dementia can be scary for sufferers, while they are aware of what’s happening. Family members find it distressing when the person they know and love switches personality, forgets their name or no longer even recognises them.
The good news is that like most modern diseases, lifestyle choices can help to prevent dementia and prolong quality of life.
A landmark study by Cambridge university researchers identified seven lifestyle factors that could prevent one in three cases of Alzheimer’s disease. Most striking was regular physical activity. Education and reducing smoking and diet-related conditions like obesity, diabetes and hypertension were also protective.
Other research has shown that B vitamins can slow the rate of brain shrinkage by lowering homocysteine in people with mild cognitive impairment – an Alzheimer’s disease precursor. Some evidence suggests a Mediterranean diet rich in plant foods may prevent dementia onset.
New Australian research, published by researchers at Edith Cowan University, Western Australia, suggests that eating foods high in protein could reduce the risk of developing Alzheimer’s disease.
The study showed that people who ate the most protein had lowest levels of amyloid beta – clumps of protein in the brain that are the hallmark of Alzheimer’s disease.
The researchers investigated the diets of 541 cognitively normal adults and found that people who consumed around 118g of protein per day were twelve times less likely to have high amyloid beta levels than those who ate only 54g per day.
Lead author, Dr Binosha Fernando, said it’s not clear how protein might reduce Alzheimer’s disease risk. He speculated that a high protein diet may exert its effects by lowering blood pressure. High blood pressure increases risk of heart disease, stroke and dementia.
Dr Fernando suggests that eating 120g of protein per day could give people the protective effect their study showed. For instance, he says, you could have a mixed bean salad with tuna for lunch, a serve of chicken with salad for dinner and a handful of peanuts in between.
Good protein sources include animal foods like eggs, dairy, chicken, fish and meat, and plant foods like legumes (e.g. chickpeas, lentils, red kidney beans) and nuts.
Protein intake is one of several confusing nutrition messages. This study supports other research suggesting we need more protein than is currently recommended. Particularly in aging, protein can also help prevent other conditions like sarcopenia and osteoporosis.
One of our staff recently spoke with someone whose father is in an aged care facility. They discovered he had a hairline fracture in his hip – about a week after it happened. The nurse accidentally dropped him when she was helping him out of bed, and it wasn’t reported.
Around one in three older adults suffer from falls, and up to 60 percent will suffer an injury. Three times more people tumble in long-term aged care.
Most injuries are superficial cuts, grazes, bruises and sprains. Some are more serious. Falls cause 40 percent of injury-related deaths in older adults. Hip fractures are the most serious and costly fall-related injuries, resulting in 19,000 hospital admissions for older Australians from 2011 to 2012.
More broadly, falls – and fear of falling – can impact independence and quality of life. But it’s not a cross lotto. Older people can reduce their risk of falls with nutrition and exercise.
Assessment tools can predict risk of falls, to help tailor prevention strategies. These tend to assess physical capacity like mobility, balance, strength and gait. But nutrition status is also a key predictor for likelihood of falling and the gravity of injuries.
Malnutrition and low body weight result from depleted protein and energy stores. This carries multiple adverse outcomes including bone loss and fragility, poorer movement coordination, slower reaction time and diminished muscle strength – all of which increase risk of falling.
Low calcium and vitamin D impact bone health and risk of falls. Low vitamin K also increases bone fragility. Poor eyesight can compound propensity to fall, also impacted by nutrition status. Low levels of vitamins A, C and E contribute to weak vision.
Insufficient vitamin B12 and folic acid can reduce nerve function in extremities, and in the brain lead to confusion. Dehydration, a common problem in older adults, can also cause delirium, as well as constipation and low blood pressure; all increasing fall risk.
Providing a healthy, tasty diet high in protein from eggs, dairy, fish, chicken, nuts and legumes and a variety of foods from the core food groups is an important step towards preventing nutrient depletion and associated risk of falling.
Regular physical activity is important to reduce age-related loss in muscle mass and bone density. Recently, the SUNBEAM trial (Strength and Balance Exercise in Aged Care), tested a program of individually tailored physical activity in aged care.
The program reduced falls by 55 percent, larger than any other study to date according to lead investigator Jennie Hewitt, physiotherapist from Feros Care and PhD candidate at the University of Sydney.
Over 200 aged care residents from 16 facilities in New South Wales and Queensland took part – half of them were randomised to do the program and the other half continued normal activities.
Participants in the program engaged in 50 hours of group-based resistance (strength) training and balance activities over 25 weeks, then a six-month maintenance period.
Not only did falls decrease dramatically in the exercise program group, but participants had considerably better balance and mobility. Some found the enhanced independence life-changing, and rejoiced at being able to go out with their families.
It’s not just about falls; healthier lifestyles and greater mobility have positive ripple effects for happy aging.