The Royal Commission into Aged Care Quality and Safety found 50% of nursing home residents are malnourished or at risk of becoming malnourished.
Dietitian Connection, a collective of more than 8,000 Australian dietitians, says they are seeing growing numbers of older Australians in aged care and community care who are either malnourished or at risk of becoming so.
Dr Jane Winter, Accredited Practicing Dietitian, told HelloCare all aged care staff can play a role in supporting older people to consume the nutritional intake they require.
People entering aged care are already a “frail, vulnerable” population and, as such, are often already malnourished or at high risk of malnutrition.
They are often frail and have some degree of cognitive decline, their mobility is restricted, and it’s quite likely they have not been looking after themselves properly at home.
In addition, conditions within aged care often don’t help residents be well-nourished.
The quality of the food may be disappointing, but also the range of food on offer may not be what the resident prefers.
Staff also often lack training, both in the food required to maintain nutrition and how to support the resident to eat. For example, busy staff may remove the resident’s meal before they have finished eating, or they may not have time to sit with the resident to help them finish their meal.
“Research shows us that even if [residents are] being provided a menu that provides all their requirements, they’re not necessarily eating all of it,” Dr Winter explained.
The consequences of malnutrition
Malnutrition is clearly linked in research with higher risk of falls and fractures. It’s also associated with poor wound healing, a significant problem considering older people – particularly aged care residents – are at higher risk of developing pressure injuries.
Malnourished people also have weaker immune systems, so they’re more susceptible to infection.
Being malnourished impacts muscle strength, which in turn affects mobility and the ability to perform the activities of general daily living, which in turn leads to further muscle loss.
“It becomes a cycle,” said Dr Winter.
Illness can also contribute to malnutrition. When people don’t feel well their appetite decreases, they stop eating and decline further.
Malnourished people also tend to have poorer quality of life, she said.
Identifying malnutrition in aged care
All aged care staff can play a role in identifying malnutrition, encouraged Dr Winter.
Kitchen staff, chefs and carers can look out for unfinished meals, and if they do notice a resident hasn’t finished their food, they can alert the clinical team.
Residents with special diets, such as for cholesterol or diabetes, require attention in case it may be limiting their food choices or needs adjusting.
Carers can monitor if clothes have become looser or dentures don’t fit properly – both are indicators of weight loss.
And, of course, simply observing residents for a “drawn” look can tell you they have lost weight.
Screening tools, such as the Mini Nutritional Assessment (MNA) short form and the Malnutrition Screening Tool (MST), can also be used to check for malnutrition.
“Anyone who has any interaction with [residents] should be on the lookout for the signs,” Dr Winter said.
Once identified, malnutrition needs to be addressed quickly.
“You need to be quite aggressive in trying to improve their nutrition quickly because it’s very hard to reverse malnutrition in older people.”
Dietitians assess factors such as muscle wasting, skin integrity, weight and food intake to come up with a measure of malnutrition, from well nourished through to mildly malnourished, moderately malnourished or severely malnourished.
Reversing malnutrition
“Reversing malnutrition is really hard for older people,” Dr Winter said.
The elderly don’t automatically regain their appetite after they go through a period of poor food intake like younger people do.
Environmental factors can also be used to improve food intake. For example, make sure the older person has time to eat their meal, they have the assistance they need to eat, check their utensils are within reach, or assess if they need a bowl rather than a plate.
A peaceful, calm and quiet environment with minimal distractions is also important, especially for those with cognitive decline.
Pleasant food aromas can help improve appetite, as can allowing greater choice over the food available – “not just being served up whatever is on the menu”.
Every meal, including snacks, should be an opportunity to consume protein, said Dr Winter.
“Protein is really important for [residents], but we need to try and get it in throughout the day, and not just rely on one big meal providing it.”
Dr Winter suggested dairy products, such as yoghurt, milk coffee or a milkshake, are suitable snacks for between meals.
When a resident has lost a lot of weight and is struggling with food intake, oral nutritional supplements can be given.
“They are much higher in protein and have all of the micronutrients as well in them,” shared Dr Winter.
They can take the pressure off eating so the focus can go back to eating for enjoyment, Dr Winter suggested.
Helping the person be as active as possible is also helpful, having the dual effect of stimulating appetite and being good for strength and muscles.
Malnutrition and COVID-19
The pandemic has created circumstances in which it is often more difficult for aged care residents to consume the nutrition they require.
Residents may not be able to attend family meals, or they may no longer be able to have meals delivered to them.
Without visitors, many will no longer have the hands-on assistance they need simply to eat a full meal.
The loss of smell and taste can also have a detrimental impact on appetite and food intake.
In addition, if a malnourished older person contracts COVID-19, they’re going to be less able to fight it. Loss of muscle mass and strength can affect breathing and swallowing, which can mean a greater chance of complications.
“COVID-19 is going to hit someone who’s malnourished very hard,” said Dr Winter.
Addressing malnutrition in aged care
In July this year, the government announced a $10 per day ‘basic daily fee supplement’, which was to be primarily spent on food and nutrition.
The measure was one of the recommendations from the royal commission.
“That’s great, but it’s not going to be the cure all,” said Dr Winter.
Aged care homes also have to look at the choice, range of foods and cultural appropriateness of their menus. They have to allow the residents to have input, and they need certified dietitians to provide advice.
Staff also need to understand that good nutrition underpins the rest of the wellbeing for residents.
Dr Winter would like to see more regular screening of residents done as a matter of course.
The main tool used to measure malnutrition in aged care is weight loss, but using a validated screening tool could trigger earlier intervention.
“If you use a validated screening tool and see someone’s at risk, then start interventions.
“Start them on a high protein, high energy diet right then, and reassess their nutritional risk a month later rather than waiting for weight loss to occur.”
“You might actually prevent that weight loss and they won’t be losing weight in the first place.”
“When someone comes in [to aged care], they might have already lost five kilos. And if you’re not going to start triggering intervention for another couple of months, then they’re a fair way down the track.”
Screening can be done on entry, and then depending on the resident, every one to three months.
Some aged care homes are “brilliant” when it comes to food and nutrition, Dr Winter said, but too often it gets overlooked.
“When you see your family not eating well, you know you’ve got to do something about it. But sometimes [in aged care] that gets misplaced. There are so many other pressures in that situation … there are a lot of other things going on, and it gets lost.”
Raise awareness in your workplace today
October 4-8, 2021 is Malnutrition Week ANZ. This is the time to put the focus on nutritious food in aged care, and ensure residents have the right food, choice and support they need to consume a nutritious diet. Only then will we see rates of malnutrition decline in aged care.
The Malnutrition Week ANZ toolkit are free, downloadable resources, flyers and social media tiles for healthcare professionals to help you raise awareness of malnutrition in your work setting. To access, click here.
For easy meal ideas for older Australians, click here to download a free recipe eBook, featuring over 20 meal ideas for breakfast, lunch and dinner, nutritious snack ideas, plus a shopping list.
A lot of the problem is staff not caring enough to help elderly to eat their meal. They serve it and walk away. Come back and if not eaten they just take it away. This happened to my mother in law. Very unsatisfactory.
I work for an organisation that has an Aged care facility, the meals provided here would have to be of the best I have ever seen in my long nursing career
Every facility should follow the lead of this organisation and have their catering department follow the Maggie Beer nutritional guide for older persons, it has changed the whole focus on good wholesome food and presentation of food for those in our care
The facility that I work in has just cut back on food. I work for a big corporation and the meals are disgusting. Carers do not care. Trays are taken away too early. Care plans are not followed. Dining room is loud and kitchen staff more interested in washing the dishes than serving the residents. Shameful.