- Five facts everyone should know about nutrition
- Why is nutrition important for older people in hospital?
- Under-nutrition or declining nutritional status/impact on other domains
- What are the causes of under-nutrition in older people in hospital?
- What can be done to help older people maintain nutrition?
- How can I recognise problems with nutrition?
- What can I do if I recognise that someone has problems with nutrition?
- Ways to enhance the nutritional intake of older patients
- What are the care or management principles that I should follow to maintain adequate nutrition for older people in hospital?
- What needs to be considered when planning discharge to help older people maintain adequate nutrition?
- What can patients, families or carers do to help an older person maintain adequate nutrition in hospital and at home?
- Tips for carers to help maintain adequate nutrition at home
- Case study
- Under-nutrition in hospitalised older people is common and poorly recognised. Nutrition risk screening on admission is essential for early problem identification and management.
- Under-nutrition or declining nutritional status may impact on other domains of functioning.
- Nutrition is the responsibility of the whole organisation. Food is an important part of the treatment and care of patients.
- Older people often need assistance and encouragement to enable them to meet their nutritional requirements in hospital.
- Simple strategies that involve the interdisciplinary team (such as Protected mealtimes and Communal dining) can assist with optimising nutritional intake.
- Under-nutrition occurs in 25-30 per cent of hospitalised older patients.
- Under-nutrition is a risk for 46-61 per cent of older hospitalised patients [124-129].
Under-nutrition is a state of energy, protein or other specific nutrient deficiency, which produces a measurable change in body function and is associated with worse outcomes from illness. Under-nutrition is reversible with nutritional support .
Under-nutrition can contribute to functional decline, increased hospital length of stay and increased hospital complications such as infections, longer rehabilitation and increased mortality [1, 121, 122].
A low body mass index (BMI), less than 22kg/m2, at discharge has been identified as an independent predictor of the development of a new disability in basic activities of daily living .
Causes of under-nutrition in older people include:
Reduced smell and taste
Dental health issues
about food, nutrition and food preparation
Poverty or food insecurity
Inability to access an adequate food supply.
Although there is no one method of determining under-nutrition, low BMI, recent weight loss and poor appetite are used as markers 
Good nutrition and hydration is important in maintaining healthy skin and plays a key role in wound healing.
Good nutrition is important in maintaining muscle mass and strength which, in turn, are important for maintaining mobility. In addition, being physically active assists with stimulating appetite and therefore assists with maintaining good nutrition. Queensland Health's Preventing falls and harm from falls in older people: Best practice guidelines for Australian hospitals and residential aged care facilities includes information on the role of nutrition.
Loss of appetite and weight loss can be a sign of depression. Therefore, being depressed can have a significant impact on nutritional status.
Impaired cognition can impact food intake due to poor concentration and confusion about eating.
There are a range of medications that may impact on food intake, including appetite-reducing medications and medications that cause nausea.
Some people with dementia may develop specific swallowing problems or other problems associated with eating. These may include not recognising food or feeding utensils, impulsive overloading of the mouth and being distracted from the task of eating.
Optimal fluid and fibre intake are important aspects of any continence management plan.
There are increasing numbers of older people who are overweight and obese. Obesity in the older person can be associated with poor physical performance, functional limitations, cardiovascular disease, diabetes and high blood pressure . However, even in this group, unintentional weight loss has been shown to increase mortality . Therefore, weight loss is not encouraged unless current weight significantly impacts on quality of life. Only well older people should attempt weight loss.
Factors relating to the food supply, such as nutritional adequacy, range of choices and the individual's cultural, religious or personal requirements or preferences.
Inadequate staffing resources for meal set up, feeding assistance and encouragement may compromise access to food. Positioning of meal trays out of reach and difficulty in opening packaged foods can also restrict food access.
Environmental and social factors around eating. These include the physical environment (for example, a dining room compared with bedside eating or the presence of unpleasant sounds or smells in the eating environment), social interactions at mealtime and insufficient time to eat a meal before it is taken away or becomes too cold to consume.
Interruptions to mealtimes by ward rounds, medication rounds and therapy sessions unrelated to food intake or nutrition.
Fasting for tests and procedures or other reasons for missed or interrupted meals.
Staffing factors including knowledge, attitudes and priority given to nutrition by staff, including the nature of interactions between older patients and care providers at mealtimes.
Before commencing any intervention, it is valuable to determine staff knowledge and attitudes regarding nutrition for older people. This questionnaire can be used to establish the importance staff place on nutrition, barriers and current practice. This should be used as a baseline survey before implementing tools and resources.
This questionnaire can be adapted for use as an on-line survey
Functional decline and nutrition education
It is important that all staff gain an understanding of the role of nutrition in functional decline and the impact of hospitalisation on food intake. The following PowerPoint slides were developed to guide a presentation to staff. The presentation outlines the link between functional decline and nutrition, defines under-nutrition and its causes, specifies a minimum adequate intake for older patients and addresses ways to improve an older person's nutrition in hospital.
Due to some of the specific nutrition content of this presentation, a dietitian would be best suited to give this presentation.
The nutritional care of older people in hospital is the responsibility of the whole organisation.
An eight-step interdisciplinary framework of best practice to prevent under-nutrition in older people during hospitalisation has been developed for Australian hospitals, based on previous work in England by Age Concern . The steps are outlined below however given the extent of under-nutrition amongst older people and its consequences, it is strongly recommended this section is read in more detail.
The steps of the framework are:
Nutrition risk screen should be undertaken on admission and at regular intervals. If a patient consumes less than 50 per cent of their meals on three consecutive days this should prompt staff to refer to a dietitian. Discipline specific forms and recommendations are available throughout this section.
Hospital staff must listen to older people, their relatives and carers and incorporate their comments into the patient's nutrition care plan.
- Interdisciplinary nutritional maintenance plan
All ward staff must become food aware. A range of recommendations are available to support this process. Simple strategies have been included, such as ensuring meal trays are placed within reach of patients and that food packaging can be opened.
Hospital staff must follow their own professional codes and guidance from other bodies. A range of hospital and professional guidelines and policies are listed in this section.
Introduce Protected mealtimes
Appropriate assistance and sufficient time to eat meals should be provided. Mealtimes need to be protected to ensure non-urgent ward activities do not interfere with patients eating their food.
Identify those requiring mealtime assistance
Establish a system of simple identifiers for patients requiring assistance at mealtimes that is located with the patient (for example bedside identifiers or identifying trays).
- Use volunteers and family or carers, as appropriate, to assist patients at mealtimes
Ensure nutrition is a focus in discharge planning. Clearly communicate plans that are understood by patients, their families and carers and any health care professionals providing ongoing care. This may include advice about meal preferences, feeding positioning, set up, equipment and encouragement techniques, supplements required, special diets or ongoing dietitian referrals or management. Maintaining optimal nutrition is a key factor in preventing readmission and maintaining functional capacity upon discharge.
Nutrition assistants are allied health assistants who provide focused care on the food and nutritional needs of patients. This is an emerging role, which provides an allied health assistant role in the area of nutrition and dietetics. There is some evidence in the literature of the effectiveness of this role in improving nutritional outcomes for older patients.
For further analysis of the role of nutrition assistants, refer to:
Many older people will come to hospital with evidence of under-nutrition.
The following are indications for patients to be referred to a dietitian for a comprehensive assessment of their nutritional status and development of a management plan:
BMI less than 22 kg/m2, or appearance of being underweight.
Recent loss of appetite.
Loose fitting clothes, jewellery or dentures.
Difficulties with chewing or swallowing or with tooth decay.
Significant, unintentional weight loss of over three kilograms (or half a stone) in the last three to six months.
Poor intake or refusal of meals.Constipation or diarrhoea. Frequent infections. Pressure ulcers. Under-nutrition is often poorly recognised and can have a significant impact on the outcomes of hospital admission and may contribute to the functional decline of the older person. Many older people are already at risk of under-nutrition on admission to hospital, and the impact of illness and hospitalisation may further compromise their nutritional status. Patients should be routinely weighed during hospital admission to establish their nutritional status and the effectiveness of treatments.
A more formal way of ensuring that all patients are assessed for under-nutrition, or being at risk of under-nutrition, is to introduce routine nutrition risk screening on admission. At-risk patients who are identified early on in their admission and receive timely nutrition management, including referral to a dietitian, will have a shorter length of stay.
Nutrition risk screening
Screening is a rapid and simple process that can be undertaken by staff other than trained nutrition professionals.
Nutrition risk screening is recommended [128, 132] for all older people on admission to hospital. Screening should be completed within the first 24 hours of admission to hospital, but where the assessment of weight is complex (for example, non weight bearing patients), nutrition risk screening should be completed within 72 hours of admission.
Five nutrition risk screening tools have been selected from a large range of tools available [133-137]. All these tools have been identified as quick (less than 10 minutes) to complete and can be completed by all members of the health care team.
The choice of tool should be made based on the health care setting, who will be conducting the screening, training requirements, likely compliance and availability of follow-up care.
Other nutritional risk screening tools include:
Older people in hospital often have higher needs for energy, protein and nutrients. More energy, protein and nutrients are required to correct underweight, reverse weight loss, recover from surgery, fight infections and heal wounds.
To provide a guide to the suggested minimum amounts of food required by older patients, it is recommended that the following amounts of food be consumed daily:
- Two small serves of meat, fish, poultry or eggs (60g cooked).
- Two small serves of fat or oils (one serve = one teaspoon of margarine or oil).
- Three serves of dairy foods - full fat (one serve = 250ml milk, or 30g cheese or 200g yoghurt).
- Three serves of fruit (fresh, canned or stewed).
- Four serves of vegetables (including one serve of potato).
- Five or more serves of breads and cereals - preferably wholegrain. (One serve = one slice of bread, or half a cup of rice or pasta or three quarters of a cup of breakfast cereal).
- Six to eight cups of fluid.
This is the minimum intake and some older people will require even more food. If patients are unable to consume this quantity of food, a referral to a dietitian is required for ways to enhance intake or other alternatives.
- Identify food preferences and usual intake by asking the patient or their family/carers. Communicate these preferences to food services, the dietitian and staff completing menus.
- Ensure appropriate positioning for meals. The recommended position for patients to consume meals is seated in a chair at a table. Check the table is the correct height for the chair and the food is within easy reach of the patient.
- When patients need to eat in bed, they should be sat upright and supported in this position. Clear the over-bed table of unnecessary items or items which make for an unpleasant eating environment (for example, urine bottles).
- Provide assistance with set up and access. Ensure the meal tray is placed within reach. Patients may also need assistance with positioning, reaching items on the tray (for example, cutlery) or preparing food items. Many foods are served in unfamiliar and difficult-to-open packaging. Ensure items are opened and positioned within reach and that the older person is aware of the items.
- Provide encouragement. Often older people will have small appetites due to limited activity, illness or mood. Frequent prompting and encouragement with meals in these cases is essential. This may extend to prompting a taste of meal items or identifying the most important items to consume. The most nourishing foods should be consumed first. Avoid filling up on low energy, low nutrient value fluids. For example, have the main meal in preference to soup or have a milk drink at the mid-meal instead of cup of tea.
- Monitor and observe intake and weight. Observe the amount of food consumed by individuals, including both meals and mid-meals. Food record charts provide an invaluable record of food intake, especially when a patient's recall may be limited. The charts allow staff to understand meal patterns and food intake over the full day. Weekly weight can be used to measure the changes in nutritional status and the success of nutrition management.
- Minimise interruptions. In hospital, many patients have their meals interrupted by routine ward activities, tests, procedures or visitors. Limit these interruptions and ensure patients have sufficient time to consume meals to help maximise their food intake (refer to Protected mealtimes).
- Minimise fasting periods and missed meals. Fasting for procedures or missing meals can significantly impact on food intake. It is important to develop strategies to minimise the frequency and length of fasting, especially in the older patients. Due to their limited muscle reserves, older people are much more at risk of decline due to periods of fasting and missed meals. Staff should have alternatives for meals if meals are not available after fasting.
- Provide a social environment for eating. Eating in a group environment will enhance food intake and recognises the important social aspects of eating. Opportunities for patients to consume meals together are encouraged (refer to Communal dining).
- Allow time for meals and snacks. Older people often take longer to consume meals. Sufficient time should be allowed for patients to complete their meals in an unhurried manner.
- High energy, high protein drinks or supplementary fluids may be prescribed for patients. These have been shown to be beneficial to patients who are under-nourished or at risk of under-nutrition . Such fluids are most commonly given in between meals. Provide encouragement and ensure patients consume them. It is important to watch for displacement of food. Many older people are likely to reduce their food intake when consuming a supplementary drink. Doing so will result in no net change in total energy intake.
- Make a referral to a dietitian. Dietitians can be involved in many aspects of older patients' care. They provide comprehensive assessments of nutritional status, advice on specific diets and management of older patients at nutritional risk. The dietitian can liaise with food services to ensure patients' specific needs and preferences are met. The dietitian will also play a key role in discharge planning.
Further informationRefer to Assisting with feeding: Promoting independence at mealtimes to guide an education session with staff. It outlines the importance of assisting patients with eating through appropriate setup, supervision and prompting.
What are the care or management principles that I should follow to maintain adequate nutrition for older people in hospital?
Protected mealtimes and Communal dining
Addressing nutrition requires an interdisciplinary approach and all members of the health care team should be engaged.
Protected mealtimes and Communal dining focus on improving factors that impact on the nutritional intake of many hospitalised older patients: interruptions to meals, the requirement for additional assistance and social aspects of eating.
It is acknowledged that it may not be possible to implement all aspects of these strategies, but the principles can be adapted to suit individual settings.
The introduction of Protected mealtimes and Communal dining may take time to plan and require executive support and cultural change to ensure they become embedded in practice. It is important that all staff involved in patient care participate in planning, training and implementation.
What needs to be considered when planning discharge to help older people maintain adequate nutrition?
It is important that older people are monitored for on-going signs of under-nutrition or a decline in nutritional status following discharge from hospital. For many, their treatment to correct undernutrition will continue after discharge from hospital. It is important that weight loss is reversed and under-nutrition corrected. This ensures optimal health to reduce susceptibility to further illness or decline in function.
- Does the discharge summary provide information to the general practitioner or case manager about the older person's risk of under-nutrition and the interventions required? Including the person's weight on discharge will assist with on-going monitoring.
- Does the older person who is under-nourished, or at risk of under-nutrition, understand the importance of correcting this? Do they know the correct amount of food to eat each day? Will they require additional support to make sure they meet these recommendations?
- Does the older person have access to an adequate and complete food supply on discharge?
- If delivered meals (for example, Meals on Wheels) are required, check how the older person will manage other meals throughout the day or food on days when meals are not delivered.
- What cooking facilities does the older person have at home and are they able to use these safely?
- Check about needs for shopping, including method of transport.
- If an older person lives alone are there opportunities for the older person to become involved in social dining opportunities (formal or informal)?
- If an older person requires a special diet, such as texture-modified diets and thickened fluids, does the older person or their family or carer understand the recommendations for this? Have they been provided with sufficient information on foods to include and food preparation?
- If there is an ongoing need for nutritional supplements, does the older person or their family or carer understand where to access an ongoing supply, how much is required daily and for how long? Can they manage to prepare or open these?
- If an older person is being discharged to residential care, has information on feeding position, food preferences and the type of assistance or encouragement required been provided in handover? Consider having a feeding care plan developed to assist this.
- Does the older person require follow-up appointments with a dietitian? Has a referral been made to a community-based or Home and Community Care (HACC) dietitian? Is the older person aware of these appointments and do they understand the importance of them?
What can patients, families or carers do to help an older person maintain adequate nutrition in hospital and at home?
Tips for patients and carers to help maintain adequate nutrition in hospital:
- Communicate with staff any concerns about nutrition. This includes reporting:
- Any recent unintentional weight loss.
- Having eaten little, or a change in appetite in the last five to ten days.
- Changes in the way clothes, jewellery, or dentures fit (if these have become loose it can indicate significant weight loss).
- Medical conditions, or medications, that require a special diet or affect appetite and food intake, including diabetes, swallowing or chewing difficulties and indigestion.
- Regular use of nutrition supplement drinks.
- Ask to be weighed on admission and at regular intervals throughout the hospital stay.
- Tell staff about food preferences and usual food intake patterns.
- Alert staff to any problems related to food intake, food access or concerns relating to nutrition during hospitalisation. All ward staff can assist with addressing problems and concerns. The patient services assistants who deliver meals and provide assistance with menus can also help.
- There is a limited amount of space at the bedside. Ensure over-bed trays are kept clear of unnecessary belongings.
- For some patients, having a familiar person to encourage or assist in eating can be helpful, but others may be reluctant to eat in front of visitors. Therefore, please carefully consider whether to visit during mealtimes or be aware visitors may be asked to leave the ward during mealtimes.
- Where a patient has particular cultural or personal preferences the kitchen is unable to cater for, it may be appropriate for family or friends to bring in food from home. Any food bought from outside the hospital should be managed in accordance with the appropriate hospital food safety guidelines and policies.
It is important that older people are monitored for ongoing signs of under-nutrition or decline in nutritional status following their discharge from hospital.
- Encourage the older person to visit a doctor for a check-up and ask to go with them to discuss any concerns.
- Visit the older person during mealtimes and get a sense of what their regular diet is like and if they have any difficulties eating.
- If appropriate, have a look in their fridge and cupboards. A lack of food, too much of the same foods, or rotting or expired food may signal a problem.
- Even people who get meals delivered (for example, Meals on Wheels) may not be eating enough and their diet could still need supplementing. Delivered meals are only part of the daily diet for any older person. Meals on Wheels is designed to provide clients with a third of their daily energy and half of their daily protein needs.
- Provide assistance with shopping.
- Display posters in wards to provide patients and carers with some key messages about nutrition during hospitalisation, for example, Don't go hungry in hospital (poster).
There are a number of resources available for addressing good nutrition for older people at home. However, these resources address nutrition in older people who are well and may need to be adapted to suit the older person recovering after hospitalisation or illness.
Mr Watts is a 78-year-old male admitted to the local acute hospital following a fall in the street while shopping. His injuries included a broken arm, facial bruising, skin tears to his shin and above his eyebrow, which require sutures. Mr Watts previously has been fit and active. His blood tests indicate he has mild anaemia (Hb 94g/l).
Mr Watts lives alone. His wife, Betty, was placed in a nursing home following a stroke 10 months ago. Prior to this, Betty performed the majority of household tasks including the cooking. At home, Mr Watts's routine revolves around visiting Betty and ensuring he is there to help feed her at lunchtime. As a result, Mr Watts will often skip his own lunch and is too tired in the evening to prepare a meal.
Mr Watts and Betty's son lives 45 minutes away. He has his own young family. He visits once a fortnight and rings weekly.
Mr Watts's son reports to staff that Mr Watts has become more withdrawn over the past few months and that he has noted Mr Watts's phone conversations are limited. He is also aware that Mr Watts no longer attends the regular activities he shared with Betty, such as bowls.
After six days, Mr Watts is transferred to a sub-acute hospital for slow stream rehabilitation. Mr Watts spends most of his time alone in his room and eats very little of the hospital food as it is difficult for him to eat with only one arm while his broken arm is plastered. He receives little help from staff at mealtimes.
Eventually Mr Watts is referred to a dietitian at a team meeting during his second week of admission as he is experiencing loss of muscle mass and lacks the strength to participate in the available exercise programs. The wounds from his fall are healing very slowly.
The dietitian identifies that Mr Watts is malnourished as his BMI is less than 18.5 and he has lost a further three kilograms while in hospital. Mr Watts is able to describe to the dietitian his usual food intake at home and the problems he has been having in hospital. The dietitian prescribes high protein drinks. Mr Watts is happy to try to drink these but he struggles to open the tetra packs these drinks come in. Many drinks return on his meal tray unopened. Staff notice this but they are too busy to spend time assisting Mr Watts with his meals. Only half the nurses are available on the ward at mealtimes as the other nurses are on their meal breaks during patient meals times.
Eventually Mr Watts recovers enough to be discharged home. Mr Watts will need to continue having high protein drinks to help him return to his usual weight. The dietitian provides him with a recipe for this and encourages him to prepare this at home. She suggests Mr Watts follows up monitoring his weight via his GP, but this is not communicated to the GP in the medical discharge summary.
Unfortunately when Mr Watts gets home he becomes confused about how to make up the high protein drinks as it is an unfamiliar task. Mr Watts also lacks the motivation to do this as his appetite remains poor and he is possibly experiencing an unrecognised depressive episode. Mr Watts reverts to his previous arrangements of visiting Betty and having poor nutritional intake. Therefore he remains under-nourished and loses further weight.
Noticing a decline in his function and self-care, his GP arranges for an Aged Care Assessment Service (ACAS) assessment for low level residential care.
The following strategies from The toolkit were utilised:
- Identification and management of risk factors contributing to under-nutrition (for example, depression and psychosocial issues).
- Use of validated nutrition risk screening tool to identify nutrition risk. For further information refer to How can I recognise problems with nutrition.
- Use of a clear hospital policy that guides management of under-nutrition.
- Interdisciplinary assessment and management of nutrition issues.
- Meal time assistance.
- Benefits of communal dining. For further information refer to Protected mealtimes and Communal dining.
- Use of patient education materials. For further information refer to What can patients, families or carers do to help an older person maintain adequate nutrition in hospital and at home.
- Comprehensive discharge planning for ongoing prevention of under-nutrition strategies. For further information refer to What needs to be considered when planning discharge . to help older people maintain adequate nutrition.
After six days, Mr Watts is transferred to a sub-acute hospital for slow stream rehabilitation.
As guided by the hospital policy for patients at risk of under-nutrition, Mr Watts is referred to the dietitian and placed on a high energy, high protein diet, which includes a high protein milk drink. The nurse also requests for his meals to be cut up.
The dietitian sees Mr Watts the next day, at this time he is able to describe to the dietitian his usual food intake at home and the problems he has been having in hospital. Mr Watts enjoys the high protein drinks he has been receiving at morning tea and is happy to include another one with his dinner. He also finds that he is managing to eat more of the main meal now that it is cut up.
He is very grateful that the nurses will help to spread his toast at breakfast and the ward assistant helps put the soup in a mug and open his sandwiches.
In consultation with Mr Watts and his son, his discharge plans are developed. He is safe to return home, but his nutrition remains a concern. He has gained three kilograms during his four-week admission. The social worker arranges for Mr Watts to receive frozen delivered meals four days each week and negotiates with Betty's nursing home that Mr Watts can have access to a microwave to heat up a frozen meal during his visit. Mr Watts had heard of a community bus to assist him with shopping. The social worker encourages Mr Watts to participate in this for the social aspects but also to provide more support to him whilst shopping for food. In addition, Mr Watts's family are encouraged to share a meal with him during their visits.
Mr Watts will need to continue having high protein drinks to help him return to his usual weight. The dietitian provides him with a recipe and he is able to practice preparing this in the occupational therapy kitchen before his discharge.