Are your elders eating enough?

By Terese Scollard, MBA, RD, LD, regional clinical nutrition manager for Providence Nutrition Services

As many as one in four older adults do not get the nutrition they need.

Under-nutrition among older adults is a big problem – much bigger than most people realize. It can be triggered by a personal loss or change, a sudden medical crisis or a chronic inflammatory condition. It can result from appetite changes, functional changes or dental problems. It can happen to people with low incomes or high incomes, to people who are underweight or overweight. It can happen at home, in a nursing home or in a hospital. It is widespread, it often goes unrecognized, and its consequences are vastly underestimated.

As many as one-third to half of health problems in the elderly are thought to be related to inadequate nutrient intake. When an older person doesn't get enough nutrition, it affects thinking, functioning, mood – everything. When the brain doesn't get enough nutrition, thinking becomes confused and muddled, leading to worsening malnutrition and accelerating decline. When the muscles don't get enough nutrition, walking and daily functioning become more difficult, and falls and fractures are more likely. When an injury or illness strikes, undernourished adults get sicker, develop more infections, have more difficult recoveries and don't heal well. Psychologically, they feel worse and have fewer coping mechanisms. They are more likely to die.

My point in sharing all of this is not to scare you, but to encourage you to be on the lookout for this problem in the older people in your life. Malnutrition isn't like a heart attack, with obvious alarms that prompt immediate responses. It sneaks up on people. But there are signs you can watch for, many things you can do to prevent it, and help available if you suspect a problem.

What to watch for

The signs of under-nutrition or malnutrition may be subtle, but they add up. Watch for any of these signs, which may indicate a problem:

  • Weight loss – often noticeable around the face, temples, hands and back
  • A shrunken appearance to the large muscles
  • Clothing that appears loose or baggy
  • Changes in eating patterns, such as leaving more food on the plate or losing interest in the usual snacks
  • Functional difficulties, such as problems getting to the grocery store, hauling groceries, or cutting and preparing food
  • Failing strength, such as wobbly walking or a weakened grip
  • Changes in denture fit, or dentures that appear to be floating in the mouth
  • Rapid weight loss in an older person who has normally carried extra pounds

Malnutrition in obese people is one of the most commonly overlooked problems, because our tendency is to applaud weight loss in overweight people. While gradual weight loss is healthy in an overweight person, rapid weight loss is dangerous in anyone, especially in older people, and particularly when combined with a medical condition. Getting enough protein and calories is critical to healing and functioning. If the body doesn't get enough nutrition when it's trying to deal with an injury or illness, it uses all of its reserves dealing with the medical condition at hand, leaving little to maintain normal functions. This imbalance, called inflammatory malnutrition, interrupts metabolism and digestion, leading to more problems, including suppressed appetite.

If you notice signs of possible under-nutrition or malnutrition in an older family member or friend, don't let it slide. The worse it gets, the more damage it does and the more difficult it is to turn around. Let the person know that you've noticed some weight loss, and that you are concerned. Ask how he or she has been eating lately – but understand that it's common for older people to make excuses or to downplay potential problems, particularly if they've battled excess weight all their lives. Consider involving a respected third party, such as the person's physician, or a registered dietitian – or, ideally, both. A dietitian can perform a nutrition physical and dietary assessment that looks at multiple factors – from food intake to changes in weight, skin, and muscle and grip strength – to provide a clear assessment of the problem, and then can work with the person and the care team to implement effective strategies to prevent nutrition problems from getting worse.

How to boost nutrition in the home

In addition to working with a dietitian, there are a number of ways you can work directly with an older person to help boost nutrition in the home. For people who have not been eating enough, even 200 or 300 extra calories per day can make a huge difference in how they feel, think and function. Here are several things you can try, depending on the individual's tastes and abilities:

  • Start with what the person likes to eat most, and encourage those foods.
  • Add a homemade or prepackaged dietary supplement drink every day.
  • Drizzle olive oil on top of soups or salads to boost healthy fats and calories.
  • Stir a couple of tablespoons of milk powder into custards or puddings for extra nutrition.
  • Top toast with jam.
  • Add sauces, such as cheese sauce with broccoli or tartar sauce with fish.
  • Stock the person's freezer with homemade or high-quality purchased heat-and-eat meals for days when preparing a meal is difficult.
  • Provide pre-chopped produce to make meal prep easier, but don't do all the work for a capable person – encourage self-sufficiency as much as possible.
  • If appetite is an issue, encourage eating several small meals throughout the day.
  • If nausea is an issue, suggest chilled foods to reduce odors, and ask the doctor about medication that can reduce nausea.
  • Work with the doctor or pharmacist to review all medicines that may be reducing appetite, and organize medicines by whether they need to be taken with or without food.
  • Suggest a little snack in the evening – a bit of ice cream or a small milkshake.
  • Lighten up on food rules – don't sacrifice needed nutrition to a principle that may not apply at this stage of a person's care.
  • Sit down and eat with the person – company can make meals more pleasant.
  • Don't be afraid of food stamps – they can be a big help for seniors with limited means.
  • Make sure the person is keeping up with dental care – one sore tooth can affect chewing and swallowing enough to prevent a lot of nutrition from getting in.
  • Get help. Providence's registered dietitians can provide excellent nutritional guidance. Our occupational therapists can help with self-feeding difficulties. Our Home Health team can provide in-home nutrition therapy. And our social workers can refer you to social service agencies, such as Meals on Wheels and others.
  • Consider a visit to ElderPlace, an excellent resource for care, meals and socializing with other seniors. Watch a video of one woman's ElderPlace experience.

Preventing malnutrition when medical problems arise

An estimated 25 to 40 percent of older people admitted to the hospital are malnourished. If an older family member is scheduled for surgery and you believe that her nutrition is marginal, it may be appropriate in some cases to postpone the procedure for a couple of weeks to get her in better nutritional shape to withstand the surgery. Whether or not to postpone depends on many factors, but as an advocate for your elder, it's important to bring up the option with the medical team. A person who is well nourished before going in for surgery, chemotherapy or other extended medical care will respond to treatment better, get out of the hospital faster, and have fewer complications and a better recovery.

Before and during hospitalization, work with the care team to track your loved one's weight and eating. At every stage of care, ask: is nutrition on the care plan? Has grandma been weighed this week? How is her weight looking? What are you doing to make sure she eats? Is an interdisciplinary team conference planned, and will nutrition be covered in that? Nutrition doesn't need to be the entire focus of a person's care, but it needs to be part of it. Medical treatment and nutrition together are quite powerful – the two work hand in hand.

Finally, if a person is undergoing significant medical treatment or surgery and is unable to eat enough, discuss the option of tube feeding with a physician and dietitian. Many people fear tube feeding, thinking of it as a last-ditch effort, but in the right circumstances, it can greatly support wellness and healing during serious treatments. A temporary tube can be placed through the nose or directly into the stomach to supplement the oral diet, helping people make up for deficiencies at night. People on this therapy feel much more energetic and positive, experience less drastic weight loss, and recover better.

Nutrition is vital to strength, healing and quality of life. Don't let malnutrition sneak up on the older people in your life. Check in with them, share a meal together every now and then, and stay in touch. If you do suspect a problem, don't let it turn into a crisis – act early. Providence's dietitians, social workers, and home health and ElderPlace teams are here to help.


Terese Scollard, regional clinical nutrition manager for Providence Nutrition Services, is involved in a national effort to establish standards for diagnosing and managing adult malnutrition, as part of the Malnutrition Work Group of the Academy of Nutrition and Dietetics.