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40 AJN ▼ March 2005 ▼ Vol. 105, No. 3 http://www.nursingcenter.com

NUTRITION IN

Rose Ann DiMaria-Ghalili is an associate professor of nursing, School of Nursing, West Virginia University,Charleston Division. She is also a research consultant to the Nursing Research Council at the Charleston AreaMedical Center. Elaine Amella is an associate dean for research and an associate professor at the MedicalUniversity of South Carolina College of Nursing, Charleston. Contact author, Rose Ann DiMaria-Ghalili: [email protected]. This article is fifth in a series that’s supported in part by a grant from the AtlanticPhilanthropies to the Gerontological Society of America. Nancy A. Stotts, EdD, RN, FAAN ([email protected]), a John A. Hartford scholar, and Carole E. Deitrich, MS, GNP, RN ([email protected]), are the series editors. The authors of this article have no significant ties, financial or other-wise, to any company that might have an interest in the publication of this educational activity.

OVERVIEW: Both physiologic and psychosocial changes affect the nutri-tional status of adults over the age of 65. Malnutrition is, in fact, a greaterthreat to this population than obesity. This article reviews the intakerequirements of older adults and discusses the risk factors that can lead tomalnutrition, including diet, limited income, isolation, chronic illness, andphysiologic changes. Assessment and nursing interventions are alsoaddressed.

By Rose Ann DiMaria-Ghalili, PhD, RN, CNSN,

and Elaine Amella, PhD, APRN,BC

OLDER ADULTS

It was November in Atlantic City, New Jersey, and the line moved slowlytoward the hotel’s grand ballroom. A few of the white-haired congregantsclung to walkers. Many were accompanied by middle-aged childrenenlisted to carry the bounty: a free Thanksgiving turkey—a reward to thecasino’s regulars. One woman, slight, with a shock of hair the color of tin

and a harsh bass voice that betrayed years of smoking, argued with her daugh-ter about the car. “Just go outside and give the valet the ticket now,” the daugh-ter urged. It was an unusually warm day for November. But her motherwanted only her turkey. She growled once they picked it up. “It’s smaller thanlast year’s,” she lisped through missing front teeth. Together they headed back,at long last, toward the car.

In one sense, this was an elite group of older adults. Its members were mobileand had family able to cater to them. Yet if one were to interview everyone inthis crowd, a host of nutritional problems would likely emerge. Signs of poordental care and chronic illness are evident. Further investigation might unveil acaregiver who has spent months tending to a sick spouse and at least one personwho spends most mealtimes alone, staring out a window, barely picking at food.

Intervention and assessment can help curb thegrowing threat of malnutrition.

CE3.5Continuing Education

HOURS

[email protected] AJN ▼ March 2005 ▼ Vol. 105, No. 3 41

Jenny Santandrea, the grandmother of AJN senior editor Lisa Santandrea, celebrates her 95th birthday with a cheese pie onNovember 27, 2004. Affectionately known as “Grandma Jenny,” she lives on her own, cooks daily, loves science fiction, andevery now and then likes to “take a beer.”

As the body ages, physiologic and psychosocialchanges set the stage for poor nutrition. In fact,even in America, where obesity is on the rise,undernutrition and malnutrition are widespread inolder adults (age of 65 and older). The AmericanSociety for Parenteral and Enteral Nutrition definesmalnutrition as “any disorder of nutrition status,including disorders resulting from a deficiency ofnutrient intake, impaired nutrient metabolism, orover-nutrition.”1 According to The Merck Manualof Diagnosis and Therapy (17th edition, online), itcan be caused by a variety of factors: • inadequate intake

• malabsorption• a loss of nutrients resulting from diarrhea, exces-

sive perspiration, hemorrhage, or renal failure • drug addiction • infection

The Nutrition Screening Initiative (NSI), a multi-disciplinary coalition headed by the AmericanDietetic Association and the American Academy ofFamily Physicians, estimates that 40% to 60% ofhospitalized older adults are malnourished or atrisk for malnutrition; it also estimates that 40% to85% of nursing home residents suffer from malnu-trition and that 20% to 60% of home care patients

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required calories] of older persons.”3 But illness,injury, stress, and activity level may increase a per-son’s total daily needs.

The following is a summary of the daily require-ments for healthy older adults. • approximately 30 kcal per kg of body weight, no

more than 30% of which should be from fat5-7

• an average of 0.8 to 1 g/kg of protein6 (for exam-ple, a person who weighs 140 lbs. [63.6 kg]would need 51 g to 64 g of protein per day,which would be accomplished with three serv-ings of any of the following: two 8-oz. cups ofmilk; 5 tablespoons of peanut butter; one chickenleg; or 3 oz. of canned tuna, hamburger, orAmerican cheese); evidence suggests that synthe-sis and breakdown of protein are greater in olderadults than in their younger counterparts,8 andthey therefore require more protein

• a minimum of 1,500 mL of fluid2, 9 (certain con-ditions such as fever, fistulae, or draining woundscan increase the need for fluids; others such asrenal or congestive heart failure will decrease it)

RISK FACTORSDietary, economic, psychosocial, and physiologicfactors place older adults at increased risk for devel-oping undernutrition.

Diet. Older adults are at risk for poor nutrition asa result of having little or no appetite, problems witheating or swallowing, inadequate servings, fewerthan two meals a day, or insufficient hot meals.

Limited income has driven some older adults torestrict the number of meals they eat each day, to eatbread and drink juice in place of more appropriatefood, and to hunt for bargains while grocery shop-ping.10 They may also change their shopping stylesaccording to the time of the month; those on fixedincomes often receive funds only once a month. Freshvegetables may be an option upon receipt of themonthly check, but by the end of that 30-day period,purchases may be limited to inexpensive nonperish-ables such as cold cereal.

Isolation. Older adults who live alone may lose thedesire to cook because of loneliness. In fact, Shaharand colleagues found that the appetites of widowsoften decrease, as does their enjoyment of meals; thesefactors put them at risk for weight loss.11 Other olderadults may have difficulty cooking for themselvesbecause of disabilities or inexperience in the kitchen.10

Finally, older adults (especially those in rural areas)can be at high risk for undernutrition if they lackaccess to transportation to stores.

Chronic illness. Older adults are more likely tohave chronic conditions that affect intake. Forexample, disability can hinder the ability to prepareor ingest food, and depression can cause a decreasein appetite.2 Poor dental health (including cavities,gum disease, and missing teeth) is another risk fac-

are so afflicted.2 For those responsible for the care ofthese patients, this is important because malnutritionis associated with longer lengths of stay in hospitalsand increased costs. Furthermore, malnourishedpatients are more likely to have diminished musclestrength and wounds that heal poorly; they areprone to developing pressure ulcers, infections, andpostoperative complications.

These estimates make one point clear: in all healthcare settings today, nurses must be vigilant aboutrecognizing undernutrition and employ appropriateinterventions. To that end, this article will focus onmacronutrients (carbohydrates, proteins, and fats)and the physiologic and psychosocial changes thatmake undernutrition a real threat to older adults.

FORMS OF POOR NUTRITIONProtein-energy undernutrition is the type of undernu-trition found most often in older adults. It can becaused by either a decrease in intake or the hyperme-tabolism associated with certain conditions (such astrauma, fever, and surgery). According to theInstitute of Medicine (IOM), a diagnosis of protein-energy undernutrition requires both “clinical andbiochemical evidence of insufficient intake.”3

Physical signs include wasting, a low body massindex (BMI), and biochemical evidence such asdecreased serum albumin or other serum protein lev-els. Marasmus and kwashiorkor are two frequentlydiscussed kinds of protein-energy undernutrition.

Obesity, a serious public health concern in theUnited States and elsewhere, is a nutritional disor-der commonly seen in older adults, but the dangerit poses to them is uncertain.3 In older adults, a highBMI has not been shown to predict death, and thereis some evidence that excessive weight in old ageserves a protective function against some injuries,such as hip fracture. Furthermore, treatmentoptions for obesity in the elderly are not clearlydefined or based on evidence.4 The IOM maintainsthat the benefits and risks of weight reduction inobese older adults must be considered on a case-by-case basis.3 An additional loss of lean body mass(body tissues not containing fat or fat-free mass),already diminished with age, may not always beappropriate in the elderly, in whom the loss of fat-free mass is associated with significant morbidityand mortality. It has been suggested that ideal bodyweights for older adults may actually be higher thanthose for younger adults.4

INTAKE: DAILY REQUIREMENTSAs people age, physiologic changes affect the body’sneed for calories, protein, and fluid. As described bythe IOM, “with aging, a gradual decline in leanbody mass and an increase in body fat occur. Areduction in lean body mass results in a lower basalmetabolic rate, thus reducing energy needs [that is,


tor, as is xerostomia, or dry mouth, which impairs the“ability to lubricate, masticate, and swallow food.”8

Antidepressants, antihypertensives, and bronch-odilators can contribute to xerostomia.

Physiologic changes that put older adults at riskfor poor nutrition include a decrease in lean bodymass and the redistribution of fat around internalorgans.12-16 These changes contribute to thedecreased caloric requirements seen in older adults.8

Because lean body mass contains metabolicallyactive tissues, it burns and requires more calories.As lean body mass decreases, so does the number ofcalories required. In addition, shortening of thespine and alterations in skin thickness, turgor, elas-ticity, and compressibility can alter anthropometricmeasures. Finally, changes in taste—which can becaused by medications, nutrient deficiencies, or tastebud atrophy—can also alter nutritional intake.

FRAILTY: AN IMPORTANT CONSIDERATIONNot only are malnourished older adults prone to ad-verse health outcomes, they are also prone to frailty—which can be the start of a downward spiral. Frailty,once termed failure to thrive in older adults, is nowconsidered a distinct syndrome, a precursor to or acause of disability.17, 18 A general definition of frailty isa “biological syndrome of decreased reserve andresistance to stressors, resulting from cumulativedeclines across multiple physiological systems, andcausing vulnerability to adverse outcomes.”17 TheCardiovascular Health Study Research Group definedfrailty as a condition in which at least three of the fol-lowing five symptoms are present: weakness, a slowwalking speed, a low level of physical activity, unin-tentional weight loss, and exhaustion.18 Malnutritionhas been identified as one of the four causes of frailty.19

Others include atherosclerosis, cognitive impairment,and sarcopenia. Frail older adults are more likely todie, be hospitalized, or become disabled.18 Restrictivediets may be contraindicated in frail older adults whoare institutionalized.2

SCREENING AND ASSESSMENTBecause nutritional assessment is essential to pre-venting disease and promoting health in older adults,it should become routine when caring for this popu-lation.2 Many components of such an assessment—determining weight, height, weight history, andfunctional limitations—are already standard. But amore in-depth assessment, in which status is deter-mined by analyzing “clinical, dietary, and social his-tory; anthropometric and biochemical data as wellas drug–nutrient interactions,” is necessary.20

Screening tool. The Mini Nutritional Assessment(MNA) is a two-part tool that can help nurses iden-tify older adults at risk for or suffering from malnu-trition.21 The first part assesses food intake,mobility, and BMI and assesses for weight loss, psy-

chological stress or acute disease, and dementia orpsychological conditions. It takes about three min-utes to complete. If a patient scores 11 points orless, the second half of the MNA provides a morein-depth nutritional assessment. The MNA is avail-able through the Hartford Institute for GeriatricNursing’s Try This series at www.hartfordign.org/resources/education/tryThis.html (click on “AssessingNutrition in Older Adults”).

When an older adult is found to be at risk for orsuffering from malnutrition, immediate consulta-tion with an interdisciplinary health care team thatincludes a dietitian or nutrition support nurse, apharmacist, and a physician is imperative.

Assessing dietary intake is important in everyclinical setting. In an inpatient setting, if a patienthas lost weight, is in a hypermetabolic state, or haslow serum protein levels or wounds that aren’t heal-

TIPS FOR NURSES: BETTERNUTRITION IN OLDER ADULTS

Hospital• Frequently reassess the patient’s nutritional status so

proper nutritional interventions can be administered ina timely fashion.

• Keep track of how much a patient is actually eating.Consider using supplements.

• Provide information to elderly caregivers on how tomaintain their own nutritional health.

Nursing Home• Keep yourself and nursing assistants up to date on

Nutrition Care Alerts (found at www.cdhcf.org/nsi/NCA%20Nursing%20Facilities.pdf).

• When appropriate, encourage family members to assistwith meals.

• Oral supplements should be served between meals.Supplements should not replace meals and should not beserved within the hour preceding a meal.

Ambulatory Care• Obtain a careful weight history and carefully measure

weight and height at each visit. Height could decreaseover time in the older adult.

• When appropriate, provide instructions on how toincrease calories and protein intake.

• Refer to community agencies if there are limitations toshopping or preparing foods.

Home Care• Refer to community agencies if there are limitations to

shopping or preparing foods.• Provide instructions on how to increase calories and pro-

tein intake.• Monitor trends in weight. Alert primary care provider if

patient is losing weight so interventions can be instituted.


dietitian regarding possible problems. However, in acomparison of estimates of food consumption com-pleted by master’s-prepared nurse researchers and cer-tified nursing assistants, (40 residents were followedfor three meals on three consecutive days), the certi-fied nursing assistants’ estimates of how much foodeach resident consumed were considerably higherthan the estimates made by nurses. In fact, only 16%of nurses and certified nursing assistants agreed.22 Thisis not surprising, however, because most certifiednursing assistants reported having trouble remember-ing the percentage of food the patients ate when com-pleting charts, and some assistants didn’t understandhow to estimate percentages. These findings reinforcethe fact that regular monitoring of the auxiliary staff’scharting is necessary, especially when patients or resi-dents are nutritionally compromised.

Anthropometry employs measurements of heightand weight to assess nutritional status; both meas-

ing properly, nurses or nursing assistants may beasked to document intake with a calorie count (alsoknown as a nutrient intake analysis) for a specifiedperiod.20 This is especially important if it’s unclearwhether a patient’s dietary intake is adequate for hisneeds. In outpatients, these same concerns mayprompt a request for a dietitian to provide a food-frequency or a dietary-recall questionnaire, in whicha patient reports everything he has had to eat ordrink over a set period (usually 24 hours).

In nursing homes that receive Medicare funding,certified nursing assistants record the percentage offood consumed by each resident at each meal. Whenthe percentage drops below 75%, a nurse is requiredto perform a full assessment, including checking theresident’s records, dietary flow sheets, dietary progressnotes, and assessments. In addition, the nurse shouldask the patient about the reasons for his decreasedintake, as well as confer with the direct care staff and

FIGURE 1. FOOD-GUIDE PYRAMID FOR OLDER ADULTS

Copyright 2002 Tufts University. Reprinted with permission.

USE SATURATED AND TRANS FATS, SUGAR, AND SALT SPARINGLYSaturated and trans fats = •Added sugar = ^Salt = *

CALCIUM, VITAMIN D, VITAMIN B12

SUPPLEMENTSNot all people need these supplements, check

with your health care provider

LOW- AND NONFAT DAIRY PRODUCTS3 or more servings

BRIGHT-COLOR VEGETABLES3 or more servings

WHOLE, ENRICHED, AND

FORTIFIED GRAINS AND CEREALS6 or more servings

WATER/LIQUIDS8 or more servings

DRY BEANS AND NUTS, FISH, POULTRY, LEAN MEAT, EGGS

2 or more servings

DEEP-COLOR FRUIT2 or more servings

Choose whole grains and fortified foods such as

brown rice, 100% whole-wheat bread, and

bran cereals

Choose water, fruit or vegetable juice,

low- and nonfat milk, or soup

= High-fiber choices


urements are used to calculate the patient’s BMI,which is used to diagnose obesity and underweight.Because of the importance of these two measure-ments, nurses should be cautious in delegating thisresponsibility to nursing assistants. If they decide todo so, interrater reliability can be established byrechecking the patient’s measurements and compar-ing them to the nursing assistant’s findings. Thisshould be done on a regular basis.

Height. In the elderly, it’s even more important torecord measured height and not self-reportedheight; because of the shortening of the spine, self-reported height may be off by as much as 2.4 cm.13

The recommended procedure for measuring bodyheight in an adult is to use a measuring rod on a bal-ance beam scale. With shoes removed, the patientstands as straight as possible and looks straightahead. The measuring rod is lowered onto thecrown of the head. In those who can’t stand orstand erect or who have spinal curvature, measure-ment of knee height can be used. Detailed instruc-tions on this procedure from the Long Term CareInstitute can be found at www.fiu.edu/%7Enutreldr/LTC_Institute/materials/LTC_Products.htm#7.

Weight. Both current weight and weight historyare crucial components of an accurate nutritionalassessment. When completing a weight history, it’simportant to note the patient’s usual body weightand any history of weight loss, including whetherthe weight loss was intentional or unintentional andover what period it occurred. A loss of 10 lbs. overa six-month period—whether intentional or unin-tentional—is a red flag indicating the need for fur-ther assessment. Large-scale epidemiologic studiesof older adults associate a history of weight losswith increases in morbidity and mortality rates.3

BMI. Once accurate measurements of weight andheight are obtained, BMI is calculated as follows:weight in kilograms is divided by height in meterssquared. But the appropriate BMI for older adults isin dispute. According to the NSI in 2002, the recom-mended BMI range for an older adult is 22 to 27,with low values indicating underweight and highvalues indicating overweight.2 In comparison, theNational Heart, Lung, and Blood Institute recom-mends a BMI in the range of 18.5 to 24.9, regardlessof age.7 Nonetheless, most experts on geriatric nutri-tion endorse the NSI’s recommendations.

Assessing visceral proteins. Serum measurementsof visceral protein levels can help determine the size ofthe visceral protein pool and, therefore, whether thepatient’s nutritional intake is adequate. The most fre-quently measured levels are those of albumin, trans-ferrin, prealbumin, and retinol-binding protein.

The serum albumin level, which has a half-life of21 days, is a good indicator of a patient’s nutritionalstatus a few weeks prior to testing and can help inidentifying chronic undernutrition. A serum albu-

min level of less than 3.5 g/dL is considered an indi-cator of an elevated risk of poor nutritional status,including malnutrition.23 For example, an albuminlevel of 4 g/dL on June 21 would suggest that thepatient’s nutritional status was relatively normalaround June 1. A low albumin level is associatednot only with malnutrition but also with death.

A problem with interpreting the significance ofserum albumin levels is that levels are inverselyrelated to hydration. A person who is overloadedwith fluid might have a very low serum albuminlevel, and a person who is dehydrated might have avery high serum albumin level; neither findingwould reflect true nutritional status. Albumin is alsoan acute phase reactant—during acute stress orinjury, albumin may be suppressed as the body goesthrough an inflammatory response. But of all thevisceral protein measurements, the test for theserum albumin level is the cheapest and the onethat’s most commonly documented.

Prealbumin and retinol-binding protein levels areuseful indicators of nutritional status in acute orsubacute settings because of their short half-lives.23

Prealbumin has a half-life of 72 hours, while that of retinol-binding protein is only 12 hours.Transferrin, which acts as an iron-transporting pro-tein, has a seven-day half-life, which is significantlyshorter than that of albumin. But because it’s relatedto iron levels, the transferrin level may not alwaysbe a sensitive indicator of nutritional status. Testsfor transferrin, albumin, prealbumin, and retinol-binding protein levels have to be ordered specifi-cally; those for prealbumin and retinol-bindingprotein levels are the most costly. The normal rangeof prealbumin is 19.5 to 35.8 mg/dL, that of retinol-

NUTRITION SUPPORT NURSINGAn evolving specialty.

The role of the nutrition support nurse has evolved over thelast four decades. Early professionals in this field were pri-

marily assigned to provide care for patients receiving totalparenteral nutrition, including IV site care and maintenance,patient monitoring, and interdisciplinary education. Manyworked as part of multidisciplinary nutrition support teams,which were popular in U.S. hospitals before the early 1990s.But many of these teams (and the nutrition support nursingjobs they created) disappeared as a result of financial con-straints and downsizing.

Currently, the major practice areas for nutrition support nursesinclude clinical practice, academia and research, and entrepre-neurial ventures. It is expected that in the 21st century, practiceareas will focus on obesity management and the elderly. Forinformation on becoming certified as a nutritional support nurse,go to www.ptcny.com/clients/NBNSC.Guenter P, et al. JPEN J Parenter Enteral Nutr 2004;28(1):54-9.


status that can remain into the unmonitored post-discharge period. This is a concern because, accord-ing to requirements of the Joint Commission onAccreditation of Healthcare Organizations, a nutri-tional assessment is required only within 24 hoursof a patient’s admission. When screening only takesplace early during a hospital stay, clinicians mayoverlook worsening nutritional status in elderlypatients later on. When patients are hospitalizedlonger than a week, nutritional reassessment needsto become part of the routine plan of care.

INTERVENTIONSA referral to a dietitian should be made as soon asundernutrition is diagnosed or identified as a possi-bility. A pharmacist may review the patient’s med-ications to determine the presence of drug–nutrientinteractions (many medications can cause anorexiaor alter taste or appetite), and a multidisciplinaryteam specializing in nutrition should be consulted.The following interventions can improve the nutri-tional status of your patients.

binding protein is 3 to 6.5 mg/dL, and that of trans-ferrin is 230 to 390 mg/dL.23, 24

When does undernutrition begin? It’s unknownwhether hospitalized elderly patients are admittedwith preexisting protein-energy undernutrition ordevelop it during their hospital stays. In a study one ofthe authors (Rose Ann DiMaria-Ghalili) conducted ofelderly patients who had undergone elective coronaryartery bypass grafting,25 albumin and transferrin lev-els and BMIs were within normal limits in the major-ity of patients before admission during preoperativetesting, but 85% of patients had a 0.5 g/dL or greaterdrop in albumin levels five days postoperatively and99% of patients had a drop in transferrin levels dur-ing the same period. Four to six weeks after discharge,albumin and transferrin levels had returned to normalin most patients, but BMIs had decreased in 95% ofelderly patients, and the more weight patients lost, themore likely they were to be rehospitalized and reportlower levels of physical health.26

These data suggest that hospitalization of elderlypatients can cause profound changes in nutritional

Nutrition Assessment

Functional gastrointestinal (GI)

tractYes

Diffuse peritonitis, intestinal obstruction, intractablevomiting, ileus, intractable diarrhea, gastrointestinalischemia

Long-term:gastrostomy,jejunostomy

Parenteral nutrition (PN)

Normal

No

Enteral nutrition Short-term:nasogastric,nasoduodenal,nasojejunal

GI function

Compromised

Standard nutrients Specialty formulas

Nutrient tolerance

Inadequate PN supplementation

Adequate; progress to oral feedings

Adequate; progress to morecomplex diet and oralfeedings as tolerated

Short term Long term or fluid restriction

Peripheral PN Central PN

GI function returns

Yes No

Progress to total enteral feedings

FIGURE 2. NUTRITION SUPPORT ALGORITHM

Reprinted with permission of the American Society for Parenteral and Enteral Nutrition (ASPEN). ASPEN Board of Directors.Clinical pathways and algorithms for delivery of parental and enteral nutrition supports in adults; 1998. p. 5. ASPEN does notendorse the use of this material in any other form than its entirety.


Alleviate dry mouth. Instruct patients with drymouth to avoid caffeine; alcohol and tobacco; anddry, bulky, spicy, salty, or highly acidic foods.8

Actions that can be taken by the patient include eat-ing sugarless hard candy or chewing gum to stimu-late saliva (not appropriate for patients withdementia or dysphagia), applying petroleum jelly tothe lips and dentures, and taking frequent smallmouthfuls of water.

Improve oral intake. You can implement severalstrategies in the hospital setting to encourage eatingat mealtimes. • Walk around at mealtimes to determine how much

food is being consumed and whether assistance isneeded.27

• Take your breaks before or after mealtimes,whenever possible, to ensure that adequate staffare available to help patients with meals.

• Encourage family members to visit at mealtimes.Ask them to bring favorite foods from home, aslong as they are in keeping with the patient’s diet.Ask about the patient’s food preferences.

• Suggest small, frequent meals with adequate nutri-ents to help patients regain or maintain weight.Ask dietary services to provide nutritious snacks.

• Remove bedpans, urinals, and emesis basinsfrom rooms before mealtimes.

• Administer analgesics and antiemetics on aschedule that will diminish the likelihood of painor nausea during mealtimes.

• Serve meals to patients in a chair if they can com-fortably get out of bed and remain seated.

• Create a more relaxed atmosphere by sitting atthe patient’s eye level and making eye contactwhen feeding her.28

• Order a late food tray or keep food warm ifpatients are not in their rooms during mealtimes.

• Don’t interrupt patients for rounds and non-urgent procedures during mealtimes.5

• Help patients with mouth care and placement ofdentures before food is served. Provide specialized nutrition support. Older adults

should be started on specialized nutrition support ifthey can’t, shouldn’t, or won’t eat adequately and ifthe benefits of improved nutrition outweigh the asso-ciated risks.1 (See Figure 2, page 46.) Among the risksof parenteral nutrition are catheter-related infection,hyperglycemia, metabolic bone disease, fluid andelectrolyte disturbances, and elevations in liverenzyme levels.29 Among the risks of enteral tube feed-ing are aspiration pneumonia, fluid and electrolyteimbalances, feeding intolerance, and gastrointestinaldisturbances.

While older adults receiving home parenteralnutrition are routinely monitored in the home setting,there may be a gap in the delivery of professional careto older patients sent home receiving tube feedings.30

In a recent study of older adults receiving home

enteral nutrition, complications led to unscheduledhealth care visits and readmissions; an interdiscipli-nary approach to monitoring these patients in thehome is clearly needed.30

Use volunteers. Eating is the most time-intensiveactivity of daily living, but trained volunteers canhelp set up meal trays, assist with feeding, and keeppatients company during meals. It’s especially impor-tant to ensure adequate staffing at mealtimes; thefailure to do so has been linked to poor care, such asspending too little time assisting people with meals(which can lead to dehydration).31, 32 However, allvolunteers should be instructed in safe methods ofimproving intake in patients with dementia or neu-romuscular disorders (see “Feeding patients withdementia or neuromuscular disease,” page 48).

Provide oral supplements. High-calorie, nutrient-rich supplements are a good intervention for peoplewho are unable or unwilling to eat. The NSI statesthat improvements in body weight and survivalhave been shown in patients receiving oral supple-ments.2 For example, one study of illness related tomalnutrition in older adults concluded that “oralnutritional supplements have a greater role thandietary advice in the improvement of body weightand energy intake.”33

There are a variety of supplements, including thosecreated for patients with diabetes, chronic obstructivepulmonary disease, renal disease, and liver disease.Some of these products are enriched with fiber; sup-plements are also available as pudding, soups, coffee,and clear liquids. Supplements are not designed toreplace meals but should be provided between meals(not within the hour preceding a meal) and at bed-time. But because Medicare will not pay for oral sup-plements after discharge, the cost may be prohibitiveto an older person on a limited or fixed income.Instruct patients and caregivers in how to take inadditional calories and protein. (See Suggestions forIncreasing Protein Intake, page 48.)

‘A NEW LOOK AT THE OLD’ ONLINEA series of Webcasts designed to improve multidisciplinary care.

Further explore the topics presented in the series “A NewLook at the Old” by going online; over the course of the

series 15 free Webcasts will run, created through a collabora-tion of AJN, the Gerontological Society of America, and PRIMEDIA Healthcare, and sponsored in part through a grantfrom Atlantic Philanthropies. The first, “The Challenge to Come:The Care of Older Adults,” premiered on January 18. The sec-ond, “Presentation of Illness in Older Adults,” was available asof February 21. For information about the schedule or to view anarchive of previous Webcasts, go to www.nursingcenter.com/AJNolderadults. This Web page includes a forum for commentsand questions about the Webcasts or articles in this series.


There are three ways to improve eating in peoplewith dementia: changing the environment in whichmeals occur, changing the caregiver’s behavior, andchanging the patient (through medications such asanticholinesterase inhibitors).34, 35 Whether or notmedications are involved, the first two methodsshould always be attempted.

The first step in changing the environment (espe-cially within institutions) is to assess the area wheremeals are served. Research shows that severalactions greatly help the patient focus on meals,including trying to create a homelike environment bypreparing food close to the place where it will beserved to stimulate senses; observing as many formerrituals as possible (such as handwashing and sayinga blessing); avoiding clutter and distractions; main-taining a pleasant, well-lighted room; and trying tokeep food as close to its original form as possible.

Other suggestions include• making sure that the patient’s glasses and hearing

aid are in good working order.

SPECIAL CONSIDERATIONSThe “nothing by mouth” order. In preparation forcertain diagnostic tests or procedures, patients areoften instructed to take nothing by mouth after mid-night. When possible, schedule older adults for thesetests or procedures early in the day to decrease thelength of time they are not allowed to eat and drink.If testing late in the day is inevitable, ask the physi-cian whether the patient can have an early breakfast.

Feeding patients with dementia or neuromuscu-lar disease. Nurses may be the first health care pro-fessionals to realize that a patient is having difficultieseating. When this occurs, referrals are called for: adietitian, a dentist, a speech therapist for issues con-cerning swallowing, and an occupational therapistfor adaptive equipment such as weighted silverwareor easy-grip cups. Early involvement of the interdisci-plinary team can give the patient with dementia orneuromuscular disease a better chance of maintainingindependence. Patients with dementia who live longenough will eventually need to be fed.

SUGGESTIONS FOR INCREASING PROTEIN INTAKECottage Cheese or Ricotta

• Mix with or use to stuff fruits and vegetables.• Add to casseroles.• Stuff pasta such as manicotti or shells.

Meat and Fish• Add chopped, cooked meat or fish to vegeta-

bles, salads, casseroles, and soups.• Use in omelets, soufflés, quiches, sandwich fill-

ings, and stuffings.

Beans or Legumes• Cook and use dried peas, legumes, beans, and

bean curd (tofu) in soups or ethnic and regionaldishes. Add to casseroles, pastas, and graindishes that also contain cheese or meat.

Peanut Butter• Spread on sandwiches, toast, muffins, pancakes,

waffles, or crackers.• Use as dip for raw vegetables such as carrots,

cauliflower, and celery.• Spread on fresh fruits such as apples and

bananas.

Nuts, Seeds, Wheat Germ, and Other Ideas• Add to casseroles, breads, muffins, pancakes,

waffles, and cookies.• Sprinkle on fruit, cereal, ice cream, yogurt, veg-

etables, and salads.• Blend herbs and cream with parsley, spinach, or

basil for a pasta or vegetable sauce.

Eggs• Add chopped, hard-cooked eggs to salads, dress-

ings, vegetables, casseroles, and creamed meats.• Add extra eggs or egg whites to quiches and

to pancake and French toast batter.• Add extra egg whites to scrambled eggs and

omelets.

Milk• Use in beverages and in cooking when possible.• Use in preparing hot cereal, soup, cocoa, and

pudding.• Add cream sauces to vegetables and other dishes.

Powdered Milk• Add to regular milk and milk drinks such as milk

shakes.• Use in sauces, cream soups, casseroles, meat

loaf, mashed potatoes, breads, muffins, pud-dings, and custards.

Ice Cream, Yogurt, Frozen Yogurt• Add to cereals, fruits, gelatin desserts, and pies;

blend or whip with soft or cooked fruit.• Add to milk.

Hard or Semisoft Cheeses• Melt on sandwiches, breads, muffins, tortillas,

vegetables, eggs, or desserts such as stewed fruit or pie.

• Grate and add to soups, sauces, casseroles,meat loaf, rice, noodles, or mashed potatoes.

Reprinted with permission from Bartlett S, et al. Geriatric nutrition handbook. New York: Chapman and Hall; 1998.


• considering the need for pain medication beforemeals.

• providing therapeutic dinnerware and, when pos-sible, positioning the patient in a straight-backedchair, with feet on floor and chin slightly tucked.

• focusing on the meal. Assist as needed by relyingon cues from the patient, which may includeturning away (may signal that the patient has hadenough, or that he needs to slow down) or lean-ing forward and opening his mouth (which usu-ally means the patient wants more food).

• demonstrating what you expect the patient to do.For example, if you want the patient to chew andswallow, state this desire and then mimic thisaction using exaggerated motions.Feeding patients with advanced dementia. Care-

givers and providers may be inclined to initiate tubefeeding as a way to offset the eating difficulties asso-ciated with advanced dementia. Commonly citedreasons for the use of tube feeding in patients withadvanced dementia include preventing aspirationpneumonia, improving survival, preventing orimproving pressure ulcers, offsetting infectious com-plications, and improving functional status andcomfort level.36, 37 However, a review of the evidenceshows that there are no clear data “to support tubefeeding of demented patients with eating difficul-ties” for any of the commonly cited reasons.36 Handfeeding is still considered the best intervention, andtube feeding should only be started if the patient“continues to decline in some clinically meaningfulway”; tube feeding in this population “seldomachieves the intended medical aims and . . . ratherthan prevent suffering . . . can cause it.”37

ONGOING SUPPORTAfter discharge from an acute or subacute care setting,patients must have adequate resources to maintain ahealthy nutritional status. If a patient being dischargedhome is to maintain an oral diet, involve social serv-ices with discharge planning to ensure that the patientcan buy and prepare food. In addition, refer patientsto programs such as Meals on Wheels or services thatprovide congregate meals. Investigate the volunteerservices in your community. Often, volunteers fromlocal community groups, such as churches or highschools, can be enlisted to help shop, prepare meals,or even share meals with older adults living alone.Nurses can become an integral part of such a volun-teer force; a great community service project for nurs-ing students would be to develop community servicesthat deliver meals to older adults living at home. ▼

REFERENCES1. Guidelines for the use of parenteral and enteral nutrition in

adult and pediatric patients. JPEN J Parenter Enteral Nutr2002;26(1 Suppl):1SA-138SA.

2. Nutrition Screening Initiative. Nutrition statement of princi-ple. 2002. http://www.eatright.org/Public/Files/nutrition(1).pdf.

3. Institute of Medicine. The role of nutrition in maintaininghealth in the nation’s elderly: evaluating coverage of nutri-tion services for the Medicare population. Washington, DC:National Academies Press; 2000.

4. Kennedy RL, et al. Obesity in the elderly: who should we betreating, and why, and how? Curr Opin Clin Nutr MetabCare 2004;7(1):3-9.

5. Allison S. Institutional feeding of the elderly. Curr Opin ClinNutr Metab Care 2002;5(1):31-4.

6. Nutrition Screening Initiative. Nutrition intervention manualfor professionals caring for older Americans. Washington,DC: Greer, Margolis, Mitchell, Grunwald and Associates;1992.

7. National Heart, Lung, and Blood Institute. Clinical guide-lines on the identification, evaluation, and treatment of over-weight and obesity in adults: the evidence report. 1998.http://www.nhlbi.nih.gov/guidelines/obesity/ob_gdlns.pdf.

8. Schlenker E. Nutrition in aging. 2nd ed. St. Louis: Mosby;1993.

9. Bartlett S, et al. Geriatric nutrition handbook. New York:Chapman and Hall; 1998.

10. Souter S, Keller C. Food choice in the rural dwelling olderadult. Southern Online Journal of Nursing Research2002;5(3). http://www.snrs.org/members/SOJNR_articles/iss05vol03.pdf.

11. Shahar D, et al. The effect of widowhood on weight change,dietary intake, and eating behavior in the elderly population.J Aging Health 2001;13(2) 189-99.

12. Lehmann AB. Review: undernutrition in elderly people. AgeAgeing 1989;18(5):339-53.

13. Lipschitz DA, Mitchell CO. The correctability of the nutri-tional, immune, and hematopoietic manifestations of proteincalorie malnutrition in the elderly. J Am Coll Nutr 1982;1(1):17-25.

14. Rudman D, Feller AG. Protein-calorie undernutrition in thenursing home. J Am Geriatr Soc 1989;37(2):173-83.

Complete the CE test for this article byusing the mail-in form available in thisissue, or visit NursingCenter.com’s “CE Connection” to take the test and find other CE activities and “My CE Planner.”

ADDITIONAL RESOURCESCenter for Medicare and Medicaid Nursing Campaign onNutrition and Hydrationwww.medicare.gov/Nursing/Campaigns/NutriCareAlerts.asp

Council for Nutritional Clinical Strategies in Long-Term Carewww.ltcnutrition.org

The Role of Nutrition in Maintaining Health in the Nation’s Elderly:Evaluating Coverage of Nutrition Services for the MedicarePopulation (National Academies Press, 2000) http://books.nap.edu/books/0309068460/html/R1.html#pagetop

American Dietetic Associationwww.eatright.org/Public/NutritionInformation/92_nsi.cfm

MedlinePlus: Nutrition for Seniors www.nlm.nih.gov/medlineplus/nutritionforseniors.html

Guidelines for the Use of Parenteral and Enteral Nutrition in Adultand Pediatric Patients (ASPEN Board of Directors and the ClinicalGuidelines Task Force, 2002)


15. Bowman BB, Rosenberg IH. Assessment of the nutritional sta-tus of the elderly. Am J Clin Nutr 1982;35(5 Suppl):1142-51.

16. Chandra RK. The relation between immunology, nutrition,and disease in elderly people. Age Ageing 1990;19(4):S25-31.

17. Fried LP, et al. Frailty in older adults: evidence for a pheno-type. J Gerontol A Biol Sci Med Sci 2001;56(3):M146-56.

18. Newman AB, et al. Associations of subclinical cardiovascu-lar disease with frailty. J Gerontol A Biol Sci Med Sci 2001;56(3):M158-66.

19. Morley JE, et al. Editorial: something about frailty. J Geron-tol A Biol Sci Med Sci 2002;57(11):M698-704.

20. DeHoog S. The assessment of nutritional status. In: Mahan L,Escott-Stump S, editors. Krause’s food, nutrition, and diet ther-apy. 9th ed. Philadelphia: W. B. Saunders; 1996. p. 361-86.

21. Rubenstein LZ, et al. Screening for undernutrition in geri-atric practice: developing the Short-Form Mini-NutritionalAssessment (MNA-SF). J Gerontol A Biol Sci Med Sci 2001;56(6):M366-72.

22. Kayser-Jones J, et al. Reliability of percentage figures used torecord the dietary intake of nursing home residents. NursingHome Medicine 1997;5(3):69-76.

23. Omran ML, Morley JE. Assessment of protein energy mal-nutrition in older persons, part II: laboratory evaluation.Nutrition 2000;16(2):131-40.

24. Kratz A, et al. Laboratory reference values. N Engl J Med2004;351(15):1548-63.

25. DiMaria-Ghalili RA. Changes in nutritional status and post-operative outcomes in elderly CABG patients. Biol Res Nurs2002;4(2):73-84.

26. DiMaria-Ghalili RA. Changes in body mass index and latepostoperative outcomes in elderly coronary bypass graftingpatients: a follow-up study. Biol Res Nurs 2004;6(1):24-36.

27. Crogan NL, et al. Barriers to nutrition care for nursinghome residents. J Gerontol Nurs 2001;27(12):25-31.

28. Holzapfel SK, et al. Feeder position and food and fluid con-sumed by nursing home residents. J Gerontol Nurs 1996;22(4):6-12.

29. Worthington P. Practical aspects of nutritional support: anadvanced practice guide. Philadelphia: Saunders; 2004.

30. Silver HJ, et al. Older adults receiving home enteral nutri-tion: enteral regimen, provider involvement, and health careoutcomes. JPEN J Parenter Enteral Nutr 2004;28(2):92-8.

31. Kayser-Jones J. Inadequate staffing at mealtime. Implicationsfor nursing and health policy. J Gerontol Nurs 1997;23(8):14-21.

32. Kayser-Jones J, et al. Factors contributing to dehydration innursing homes: inadequate staffing and lack of professionalsupervision. J Am Geriatr Soc 1999;47(10):1187-94.

33. Baldwin C, et al. Dietary advice for illness-related malnutri-tion in adults. Cochrane Database Syst Rev 2001(2):CD002008.

34. Amella E. Mealtime difficulties. In: Mezey M, et al., editors.Geriatric nursing protocols for best practice. 2nd ed. NewYork: Springer; 2004. p. 66-82.

35. Lebert F, et al. Frontotemporal dementia: a randomised, con-trolled trial with trazodone. Dement Geriatr Cogn Disord2004;17(4):355-9.

36. Finucane TE, et al. Tube feeding in patients with advanceddementia: a review of the evidence. JAMA 1999;282(14):1365-70.

37. Gillick MR. Rethinking the role of tube feeding in patientswith advanced dementia. N Engl J Med 2000;342(3):206-10.

GENERAL PURPOSE: To provide registered professionalnurses with an overview of the physiologic and psy-chosocial changes that make undernutrition a seriousthreat to older adults and to propose interventions forimproving nutritional status among this population.

LEARNING OBJECTIVES: After reading this article andtaking the test on the next page, you will be able to

• discuss the various risks for and manifestations ofnutritional deficits in older adults.

• outline the dietary recommendations for olderadults.

• plan at least five nutritional assessment or interven-tion techniques for older adults.

To earn continuing education (CE) credit, follow these instructions:

1. After reading this article, darken the appropriate boxes(numbers 1–15) on the answer card between pages 48and 49 (or a photocopy). Each question has only onecorrect answer.2. Complete the registration information (Box A) and helpus evaluate this offering (Box C).*3. Send the card with your registration fee to: ContinuingEducation Department, Lippincott Williams & Wilkins, 333Seventh Avenue, 19th Floor, New York, NY 10001. 4. Your registration fee for this offering is $22.75. If you taketwo or more tests in any nursing journal published byLippincott Williams & Wilkins and send in your answers toall tests together, you may deduct $0.75 from the price ofeach test.

Within six weeks after Lippincott Williams & Wilkinsreceives your answer card, you’ll be notified of your testresults. A passing score for this test is 11 correct answers(73%). If you pass, Lippincott Williams & Wilkins willsend you a CE certificate indicating the number ofcontact hours you’ve earned. If you fail, LippincottWilliams & Wilkins gives you the option of taking thetest again at no additional cost. All answer cards for thistest on “Nutrition in Older Adults” must be received byMarch 31, 2007.

This continuing education activity for 3.5 contacthours is provided by Lippincott Williams & Wilkins,which is accredited as a provider of continuing nursingeducation (CNE) by the American Nurses Creden-tialing Center’s Commission on Accreditation and bythe American Association of Critical-Care Nurses(AACN 00012278, category A). This activity is alsoprovider approved by the California Board ofRegistered Nursing, provider number CEP11749 for3.5 contact hours. Lippincott Williams & Wilkins is alsoan approved provider of CNE in Alabama, Florida,and Iowa, and holds the following provider numbers:AL #ABNP0114, FL #FBN2454, IA #75. All of itshome study activities are classified for Texas nursingcontinuing education requirements as Type 1.*In accordance with Iowa Board of Nursing administrativerules governing grievances, a copy of your evaluation of thisCNE offering may be submitted to the Iowa Board of Nursing.

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