Elder Care In Hospital

Healthy Eating for Older Adults

Healthy eating is a key part of aging well. It is an important part of maintaining independence and quality of life. Healthy eating can help to:

  • Maintain a healthy weight
  • Promote and protect health and wellbeing
  • Lower the risk or slow the progression of chronic diseases (e.g., cardiovascular disease, diabetes)
  • Prevent muscle and bone loss which helps to reduce the risk of falling or breaking bones

Healthy eating can be more challenging as people age. There can be a decrease in appetite and disinterest in food or preparing balanced meals. The body may need less food, but need more of a certain nutrient. It is important to encourage a variety of healthy foods to make sure patients are getting enough nutrients. This includes:

  • Choosing vegetables and fruit, whole grains and food sources of protein
    • Frozen and canned options can be just as healthy and easier to prepare
  • If sense of smell or taste has changed, try adding different spices and/or herbs for flavour instead of salt
    • Some examples include: rolled oats with maple syrup and cinnamon, blended cream soups, cottage cheese and fruit with almond extract, jellies/pickles/gravies on meat, vinegar-based dressing on vegetables
  • Try varying the texture, colour and temperature of foods to make them more interesting
    • ​Add a garnish or use patterned dishes to enhance the appearance and flavour of meals

Malnutrition

"Inadequate intake of protein and/or energy over prolonged periods of time resulting in loss of fat stores and/or muscles wasting" (Dorner & Friedrich, 2018).

This includes starvation-related malnutrition, chronic disease or condition-related malnutrition and acute disease-related/injury-related malnutrition. 

The consequences of malnutrition can be physiological, biochemical, or psychological. Forty-five percent of patients admitted to hospital are malnourished, with the mean age being 66 years old (Allard, et al., 2015). Malnourished adults in acute care are at greater risk for loss of independence and/or mortality if nutritional risks are not addressed in hospital or at discharge. 

A priority of nutrition care is to have frail adults consume enough food to prevent unintentional weight loss. Older adults lose weight as they age, but the amount lost is variable. The primary concern with weight loss in frail older adults is that lean skeletal muscle is lost rather than unwanted adipose (fat) tissue.

Risk Factors for Malnutrition

Risk Presentation
Psychosocial
  • Social isolation
  • Depression
  • Anxiety
  • Lack of independence
Medications

Low appetite secondary to side effects such as:

  • Dry mouth
  • Altered taste
  • GI disturbances (nausea, vomiting, diarrhea, constipation)
  • Reduced nutrient absorption due to medication and food interactions
  • Increase in metabolic rate caused by incorrect use of thyroxine and theophylline 
Poor Appetite/Intake

This can be the result of many different factors such as:

  • Pain
  • Inactivity
  • Change in physical environment (new smells/noises, non-culturally appropriate foods)
  • Nausea/vomiting
  • Diarrhea or constipation
  • Increased alcohol consumption
  • Decreased sense of smell and taste
  • Confusion
  • Decreased mobility
  • Dysphagia
  • Diminished consciousness
  • Poor oral hygiene/dentition
  • NPO (Nothing by Mouth) restriction by physician/surgeon
  • Lack of assistance 
Chronic and Acute Illness-related Malnutrition

Many disease states can result in unintentional weight loss in this population, including:

  • Pressure ulcers
  • Chronic obstructive pulmonary disease (COPD)
  • Chronic kidney disease
  • Cirrhosis
  • HIV/AIDS
  • Stroke
  • Congestive heart failure
  • Cancer
  • Septic shock 
  • Surgery*

*Surgery increases demands on your body. Additional energy and protein is needed for successful healing because muscle is often broken down during surgery!

Screening for Malnutrition

Screening tools can be used to determine patients who are malnourished or at risk of being malnourished. Tools are typically completed within 1-3 days of being admitted to hospital and can be completed by any health care professional.

Currently, diet technicians at Nova Scotia Health Central Zone acute care hospitals are screening patients within 1-3 days of admission for malnutrition. If your hospital or unit does not have a tool in place and/or you are concerned that a patient is at risk of malnutrition, the Integrated Nutrition Pathway for Acute Care (INPAC) tool can be completed.

The INPAC tool is a validated screening tool that can be completed by any health care professional. The tool consists of the following questions:

  1. Have you lost weight in the past 6 months WITHOUT TRYING to lose this weight?
  2. Have you been eating less than usual FOR MORE THAN A WEEK?

If a patient answers YES to both questions, they should be referred to a dietitian who will complete a further assessment which may include a Subjective Global Assessment (SGA). (Canadian Malnutrition Task Force, 2019)

Care Planning & Optimizing Oral Intake

What should be in the Older Adult’s Care Plan?

Loss of Appetite

  • Check medications, altering where possible to minimize adverse effects
  • Encourage small and frequent meals and snacks. Patients should be eating every 2-3 hours
  • Serve meals and snacks that are appealing in size. Large meals can be off-putting
  • Maximize times of better appetite. If the patient is hungry in the morning, suggest a cooked breakfast
  • Choose energy and protein dense foods. Fortify foods with extra fats and/or sugars by adding oil, butter, creams, cheese sauces/spreads. This will give meals and snacks extra calories
  • Drinks can lessen intake. Provide drinks after a meal rather than before or during
  • Social interactions at meal times. Eating with others can increase total meal consumption
  • Mobilization prior to mealtime can help stimulate appetite

Fatigue/Difficulty Obtaining/Preparing Food

  • Choose easy-to-prepare meals that include:
    • Convenience foods, e.g., precut veggies/fruit, premade sandwiches, wraps and salads, rotisserie chicken
    • Frozen meals
    • Canned items, e.g., beans, fish, fruit
  • Get family support or use a food delivery service
  • Make the most of good days. Prepare snacks and meals to eat later on. Store necessary items in the freezer

Chewing and Swallowing Difficulties

  • Make sure patients with dentures have adequate dental/mouth care. Be sure dentures are clean and in place before meal times
  • If patient is unable to sit upright in a chair, have patient sit upright in bed
  • If food is too hard and patient has difficulty with tough meats, raw fruit and vegetables, consider a softer texture modified diet (mince or puree)
  • Monitor for aspiration indicators. If patient has any of these symptoms, consult dysphagia team for swallow assessment:
    • Coughing/sneezing/choking/shortness of breath while eating, wet voice, frequent chest infections, weight loss, increased white blood cell count and body temperature

Oral Nutrient Supplements (ONS)

  • Nutritionally complete, liquid supplements that contain a mix of macro- and micronutrients
  • Useful to increase protein, energy intake when used appropriately and along with other nutrition support strategies

Hydration

Older adults are vulnerable to dehydration due to physiological changes. This can be complicated by disease states. Risk factors include:

  • Older age
  • Residing in long-term care
  • Lack of accessibility
  • Requiring assistance with food/fluids
  • Incontinence
  • Cognitive impairment/confusion
  • Depression
  • Multiple medications
  • Decreased sense of thirst
  • Acute illness, diarrhea and vomiting
  • Texture modified diets (thickened liquids)

Dehydration is associated with poor health outcomes, including urinary tract infections, pressure sores, constipation, and increased risk of death.

Many older adults are reluctant to drink because it may increase time in the washroom, especially at night. Approaches to encourage patients to increase fluid intake include:

  • Aim for six to eight glasses of fluid each day
  • Drink smaller amounts more often rather than drinking large amount
  • Encouragement from family/caregivers
  • Drink enjoyed fluids
  • Use aids for drinking if needed, such as a special cup with handles
  • Provide a glass of water with medications
  • Include more soups, tinned fruit in juice, popsicles
  • Minimize drinking close to bedtime

Allard, J. P., Keller, H., Jeejeebhoy, K. N., Laporte, M., Duerksen, D. R., Gramlich, L., Payette, H., Bernier, P., Vesnaver, E., Davidson, B., Teterina, A., & Lou, W. (2015). Malnutrition at hospital admission-contributors and effect on length of stay: a prospective cohort study from the Canadian Malnutrition Task Force. Journal of Parenteral and Enteral Nutrition, 40(4), 487-497.

Canadian Malnutrition Task Force. (2019). https://nutritioncareincanada.ca/

Dorner, B., & Friedrich, E. K. (2018). Position of the academy of nutrition and dietetics: individualized nutrition approaches for older adults: long-term care, post-acute care, and other settings. Journal of the Academy of Nutrition and Dietetics, 118(4), 724-735.

Fávaro-Moreira, N. C., Krausch-Hofmann, S., Matthys, C., Vereecken, C., Vanhauwaert, E., Declercq, A., Bekkering, G. E., & Duyck, J. (2016). Risk factors for malnutrition in older adults: a systematic review of the literature based on longitudinal data. Advances in Nutrition, 7(3), 507-522.

Government of Canada. (2019). Healthy Eating for Seniors. Retrieved from: https://food-guide.canada.ca/en/tips-for-healthy-eating/seniors/

Gramlich, L. (2016). The Prevalence and Impact of Malnutrition in Canadian Hospitals: MIND THE GAP. Retrieved from Canadian Malnutrition Task Force: https://www.cag-acg.org/images/cddw/diet_gi_health_nutrition_in_canada_gramlich.pdf

Nowson, C., & O'Connell, S. (2015). Protein requirements and recommendations for older people: a review. Nutrients, 7(8), 6874-6899.

Robinson, K. (n.d.). Guide to good nutrition and hydration in older age. British Dietetic Association.

Wells, J. L., & Dumbrell, A. C. (2006). Nutrition and aging: assessment and treatment of compromised nutritional status in frail elderly patients. Clinical Interventions in Aging, 1(1), 67-79.