Briefing Paper on the Role of the Dietitian in the Prevention and
Management of Nutrition-related Disease in Older Adults
Dietitians, as members of integrated interdisciplinary and multi-disciplinary teams, play a key role in
the prevention and management of nutrition-related disease in older adults.
They are uniquely qualified to apply scientific evidence to the promotion of healthy eating,
individualised nutritional therapy and counselling to individuals and groups.
To perform their role in the prevention and management of nutrition-related disease in older adults,
dietitians must demonstrate key competences in the knowledge, skills and attitudes which underpin
gerontology and geriatric nutrition, i.e. dietitians should demonstrate an understanding of:
- basic principles of gerontology and geriatrics,
- age-related changes in physiology and metabolism leading to i.e. sarcopenia1 and frailty2,
- age-related changes in nutritional requirements and their nutritional implications (such as
anorexia of ageing which can result in loss of body weight, increased risk of morbidity, infection,
length of hospital stay, loss of autonomy and mortality),
- common age-related diseases and their nutritional impact (such as cardiovascular disease,
stroke, cancer, fracture risk, renal disease, depression, dementia, Parkinson’s disease, pressure
ulcers and common nutritional deficiencies such as vitamin B12, B6 and D deficiency).
- the impact of multiple nutritional co-morbidities that may exist at the same time in the same
individual,
- an awareness of the typical environments associated with older adults care, e.g. the home
environment, step-down rehabilitation care, long term residential care, nursing homes,
rehabilitation units or in hospital,
- relevant aspects of research in older adults care,
- functional and organic mental health,
- socio- economic consideration relevant to older age: loneliness, poverty, depression, loss of
spouse, etc,
- evidence based practice.
 Older adults in the EU
Within Europe the proportion of older people in the population is very high. This is projected to
remain so at least until 2050. The EU population over 65 years of age increased from 13.7% in 1990
to 17.4% in 2010. By 2060 it is predicted that the proportion of people over the age of 65 in Europe
will increase to 30%, corresponding to 152 million people (WHO 2002). The number of people aged
60 and above in the EU is now rising by more than two million every year, roughly twice the rate
observed three years ago. The rise of the ‘oldest old’ (those over 80 years of age) is particularly
significant. It is forecasted to increase fourfold from the 1990 value by 2060.
While the effect of demographic ageing will be felt throughout Europe, a recent study by the
Committee of Regions ‘Active ageing: local and regional solutions’ clearly showed that it will impact
some regions more severely than others.
Life expectancy continues to rise. In 2008 average life expectancy for the EU-27 it was 76.4 years for
men and 82.4 for women. Differences among member states are still very significant, ranging from
1
2
Sarcopenia is associated with diminished muscle mass and function and changed metabolic conditions.
Frailty is associated with elderly people who exhibit sarcopenia, low physical activity, decreased walking speed, low muscle strength,
unintentional weight loss and exhaustion.
Briefing Paper Older Adults
Revision June 2013
1 of 15
EFAD receives funding from the Executive Agency for Health and Consumers, under
the framework of the Health Programme. Sole responsibility for the content of this
briefing lies with EFAD and the Executive Agency is not responsible for any use that
may be made of the information contained therein.
almost 13 years for men to 8 years for women (EUROSTAT 2011). The majority of older adults live
healthy and independent lives, but there are large discrepancies among and within countries in
social, occupational and educational experiences. A number of factors, including nutrition, have
contributed to the increase in life expectancy. This offers the potential of raising average life-spans
for the less-advantaged groups. Not only are people leading longer lives, but also healthier and more
productive lives. The working population is ageing, as the proportion of older workers in employment
increases.
The older adult population can be classified into 3 categories: the pre-war generation, the silent
generation and the baby boomer generation (Becker (1993).
Generations differ strongly from each other. Seniors wish to be identified by what they find
important in life and not by the fact that they are old, as many are still active, vital and healthy.
Young seniors are often very concerned about their health and seek concrete reasons why they
should change their lifestyle. They may wish to take matters into their own hands and to make their
own choices.
The European Innovation Partnership on Active and Healthy Ageing
http://ec.europa.eu/health/ageing/innovation/index_en.htm aims to increase healthy life years by
two years by 2020.
The key priority pillars for this project are:
- prevention, screening and early diagnosis,
- care and cure,
- active ageing and independent living.
2012 was the “European Year for Active Ageing and Solidarity between Generations” emphasizing
the importance of focusing on these priorities. The European Commission aims to support the
initiative at a time when the EU grapples with a steadily ageing population and its impact on public
services and finances. The term ‘Active ageing’ refers to the creation of more opportunities for older
people to continue working, to stay healthy longer and to continue to contribute to society in other
ways, for example through volunteering.
Health promotion and preventative health care should be encouraged, through measures that
maximise healthy life years and reduce risk of dependency. Common conditions such as
cardiovascular disease and type 2 diabetes are preventable and their consequences on older adults’
wellbeing can be managed. Owing to the impact that good nutrition has on health and well-being in
later life, nutrition among older adults should be prioritised in society.
 The ageing process
According to WHO Active Ageing is built on three pillars; participation, health and security. Nutrition
is part of each of these three pillars. The main purpose is to maintain independence and prevent
disability by rehabilitation and to ensure quality of life (WHO 2002). Ageing is an irreversible and
progressive process, affecting social, mental, emotional and physiological abilities. The frailty
concept includes low physical activity, decreased walking speed, low muscle strength, unintentional
weight loss and exhaustion. It has a negative impact on physical function and quality of life, and
increases risk of injuries from falls. Sarcopenia is an important component in the frailty concept
referring to diminished muscle mass, function and changed metabolic conditions. These agedependent alterations make older adults especially vulnerable to disease-related malnutrition.
Anorexia of ageing is defined as “unintentional decline in food intake” and, as a result, weight loss,
Briefing Paper Older Adults
Revision June 2013
2 of 15
EFAD receives funding from the Executive Agency for Health and Consumers, under
the framework of the Health Programme. Sole responsibility for the content of this
briefing lies with EFAD and the Executive Agency is not responsible for any use that
may be made of the information contained therein.
that begins near the end of life; it represents a sign of failure to maintain levels of food and fluid
intake necessary to preserve energy stores.
Energy and nutrient requirements vary with health status and stage in life. Therefore ‘healthy food’
has different meanings during the life course. Normally energy and nutrient intake decreases in older
age groups. However, when intensified by disease food consumption can become too low to meet
the requirements for maintenance or the recovery of health. The consumption of appropriate
appetizing food, with adequate composition and texture is an important prerequisite for the older
person’s well-being. It is essential to facilitate and maximize the added benefit of medical treatment
and physical rehabilitation.
Nutritional differences in various groups of older adults should be identified (Suominen ea (2012)).
Multidisciplinary cooperation and education led by experts in nutrition concerning assessment of
nutrition and nutritional care of older adults is needed (Suominen ea (2007). One of the most
common nutrition problems in the older adult is disease-related malnutrition.
 Role of the dietitian in active and healthy ageing
In the ageing population, the role of the dietitian is essential. Their expertise and knowledge is
necessary in the prevention and treatment of malnutrition at a strategic, educational and operational
level for the two main target groups: the healthy older person and the sick older person, including
the frail older person.
Nutrition is embedded in the management of chronic diseases, malnutrition and functional abilities
of the older person. Nutrition also plays a preventative role and is identified as a key component of
quality of life (Perry & Mc Laren (2004)).
-
Prevention of malnutrition within the healthy older adult
This may occur at group or individual level in a variety of settings.
Within the community, programmes may consist of nutrition education workshops and practical
nutrition & cookery programmes, involving Active Retirement groups or Active Ageing groups.
These nutrition programmes are often evaluated and peer-reviewed. Their aim is to address the
risk of malnutrition and dehydration.
Although no amount of physical activity can stop the biological ageing process, there is evidence
that regular exercise and encouraging favorable lifestyle behaviours - even at advanced ages can minimize the physiological effects of an otherwise sedentary lifestyle and increase active life
expectancy by limiting the development and progression of chronic disease and disabling
conditions by older adults. So it is advisable to include recommendations for an active lifestyle
into dietitian-involved health promotion projects.
Briefing Paper Older Adults
Revision June 2013
3 of 15
EFAD receives funding from the Executive Agency for Health and Consumers, under
the framework of the Health Programme. Sole responsibility for the content of this
briefing lies with EFAD and the Executive Agency is not responsible for any use that
may be made of the information contained therein.
-
Prevention of malnutrition with frail older adults
This may require an individual dietetic consultation with appropriate follow up. The education of
these clients and /or their carers through lectures/ workshops addressing malnutrition risk is
thought to be very valuable.
The dietitian plays an important role within Primary Care interdisciplinary teams. Joint working
with the other Allied Health Professionals, Nursing, Medical and Social Services faciliates early
and rapid problem solving and enables the client to be cared for in a patient-centred holistic way.
Nutrition and its parameters should be fundamental in any generic screening tool used for
generic holistic team working.
The importance of a brief annual dietetic check-up of this age group cannot be underestimated.
It can identify malnutrition earlier and prevent a worsening condition developing, thus extending
the quality of life of older adults.
Older adults often adhere to diets they have been advised to follow when younger and/or during
the acute stage of a disease. It is the dietitians' role to explain why a strict diet may no longer be
advisable for them and the possible adverse effects of following such a diet.
The dietitian is also the right person to advise on the appropriate intake of Oral Nutritional
Supplements, both prescribed and available over the counter. These often provide vitamins,
minerals & trace elements as well as energy, protein and fat. The appropriate use of these is
based on the specific nutritional status of an individual at a particular time.
Since poly-pharmacy is common in older adults, drug-nutrient interactions are another important
issue in the nutritional follow-up. Drug-nutritient interactions may result in poor nutritional
status. Adverse drug effects are one of the most common reversible causes of protein-energy
under-nutrition. Medication can induce weight loss by causing anorexia, nausea, vomiting,
diarrhea, constipation, cognitive disturbance, or increased metabolism.
The dietitian also has a role in the nutrition-related education of the multidisciplinary team. The
development of structured education programmes with healthcare professionals in the
community (general practitioners, community/homecare nurses etc) is a valuable part of the job.
By addressing the malnutrition and dehydration risk in frail older people who are chronically ill
and may have dementia, the dietitian has been able to show significant clinical benefits and
treatment outcomes.
-
Treatment of healthy older adults
This may consist of dietary counseling for an acute medical problem requiring nutritional
adaptation to preventing the deterioration of health in this client group. A dietitian can provide
the specialist nutritional support required, tailored to the individual need of the client, which will
obviously vary from individual to individual. It is advisable to simultaneously undertake a brief
nutritional check-up (intake of fluid, energy, protein, fibres, vitamins, minerals) and weight
evaluation.
Since the outcome of treatment of some established diseases and geriatric syndromes is more
effective with higher-intensity exercise (e.g., type 2 diabetes, clinical depression, osteopenia,
sarcopenia, muscle weakness), it is advisable to motivate people to have an active lifestyle and to
cooperate in a multidisciplinary way to improve the activity level. Reducing sedentary behaviour
has recently become a target for behavioural scientists, as it has been shown that the reduction
of prolonged sitting, in obese adults, reduces post-prandial glucose and insulin responses. There
Briefing Paper Older Adults
Revision June 2013
4 of 15
EFAD receives funding from the Executive Agency for Health and Consumers, under
the framework of the Health Programme. Sole responsibility for the content of this
briefing lies with EFAD and the Executive Agency is not responsible for any use that
may be made of the information contained therein.
is a growing body of evidence that suggests breaking up sitting time approximately every 30
minutes can improve weight and metabolic outcomes.
-
Treatment of sick and/or frail older adults focusing on under-nutrition malnutrition.
Under-nutrition malnutrition risk screening should be implemented in all care settings. The
earlier this problem is recognized, the easier it is to avoid or treat. Therefore the implementation
of a validated nutrition screening tool, an appropriate malnutrition care pathway, a
communication structure and a structure for referral to the dietitian is essential in the health
care setting.
Dietitians treat malnutrition by individually-tailored intervention. A structured nutrition &
dietetic treatment process results in better outcomes for the frail older person in all care settings
and may result in cost savings for the service provider.
Dietitians should have input to all care-settings for older peoples services: acute hospital,
community residential care sites, nursing homes, community primary care teams, rehabilitation
teams and own-home care.
To deliver a ‘person centred’ approach requires an understanding of food habits. Understanding the
motivation behind these food choices is essential for compliance to a prescribed diet therapy, which
may also require the intake of oral nutrition supplements.
Dietitians specialising in the care of older adults must have a profound understanding of gerontology,
geriatric and ethical considerations and when treating this care group pay attention to the following:
- approach older adults in a respectful way and try to empower them,
- focus on changes in cognitive and physical abilities and how changes in these abilities affect the
conditions for treatment goals,
- communicate at an appropriate level of functioning and intelligence with the aid of supportive
materials:
- provide clarity - do not use jargon and technical terms,
- make use of images and clear illustrations to clarify what you explain,
- use sufficiently large font and clear signs and symbols in written matters.
- apply Cognitive Behavioural Therapy skills,
- take into consideration the financial situation, lifestyle and level of support from relatives or
social workers,
- always prioritise the overall quality of life and respect the will of the older adult3.
As previously mentioned, the role of the dietitian in care of older adults is multifactorial: strategic,
educational, clinical, administrative and evaluative.
- Strategic level
Dietitians have an important role to play within health and social care organisations. It is
essential that they are able to influence operational and strategic policy; implementing quality
and standards of care; leading and influencing appropriate change to health provision and the
processes and systems within and by so doing facilitating the coordination of nutrition related
programmes at a population level.
Dietitians often work alone and therefore rely on effective teamwork with other health care
professionals and co-workers in order to provide a holistic nutrition and dietetic service. They
3
We must be very much aware of the fact that very old adults with the greatest nutritional problems also often are not in a mental state to
be able to independently take care of what is prescribed.
Briefing Paper Older Adults
Revision June 2013
5 of 15
EFAD receives funding from the Executive Agency for Health and Consumers, under
the framework of the Health Programme. Sole responsibility for the content of this
briefing lies with EFAD and the Executive Agency is not responsible for any use that
may be made of the information contained therein.
should plan and set specific goals which should address specific areas which influence the
prevention and treatment of nutrition/disease related malnutrition within older adults care, e.g.
prevention strategies, clinical strategies, education strategies, meal structure, production and
environment strategies, evaluation strategies and physical activity to prevent falling and
sarcopenia.
-
Educational level
As qualified nutrition experts within older adults care, dietitians should work towards improving
their professional image with the public. This can be achieved by increasing their visibility in the
media, boosting their profile to both public and professional target groups.
Public target groups:
- The risk of nutrition-related disease within the older adult population should be
highlighted with the co-operation of associated community groups and organisations via
practical channels.
Professional target groups:
- Information regarding current international, national and/or local clinical guidelines for
the prevention and management of nutrition-related disease should be created and
communicated to relevant professional personnel within the older adults care
environment to promote best practice. The dietitian should demonstrate competence in
using various effective communication channels in order to communicate key messages,
e.g. local meetings, seminars, websites, e-mails, procedures, reports, personal support
etc. and should focus on being visible and accessible via these channels.
-
Clinical level
Nutrition is imbedded in the management of chronic diseases, malnutrition and functional
abilities of the older person. Nutrition also plays a preventative role and is identified as a key
component of quality of life (Perry & Mc Laren (2004)).
Dietitians should aim to follow examples of best practice when treating the older person. One
method of ensuring that this happens is to follow peer reviewed guidelines. The ‘Model and
Process for Nutrition and Dietetic Practice’, BDA 2012 is one example of how to do just this.
Dietitians in the context of patient treatment should develop a nutrition care process for the
carers to follow. To avoid problems, the nutrition intervention should always be labeled with a
nutrition diagnosis.
Dietetic input within care establishments is essential. They have an important role in menu
modification and design, making the provision of therapeutic diets possible.
In nursing homes, and other settings where food is produced, food should be manufactured in a
safe and nutritionally correct way. It should be appetizing and have a high energy and protein
content and texture modification if required.
Motivational interviewing is used to motivate the client in changing lifestyle. However, some
older adults are not candidates for diet or lifestyle changes. The dietitian always has to respect
the autonomy and wishes of the individual.
The dietitian should be a member of every primary care team. Their contribution can prevent
avoidable admissions and promote early hospital discharges. Links with social services can be
invaluable in that a dietitian can make sure that that the provision of ‘meals on wheels’, or other
social food provision, is relevant and nutritionally appropriate.
Briefing Paper Older Adults
Revision June 2013
6 of 15
EFAD receives funding from the Executive Agency for Health and Consumers, under
the framework of the Health Programme. Sole responsibility for the content of this
briefing lies with EFAD and the Executive Agency is not responsible for any use that
may be made of the information contained therein.
The dietitian should always work according to the ethical considerations of the ESPEN guidelines
for geriatric nutrition, while reducing morbidity and mortality is a priority in younger seniors, in
geriatric patients maintenance of function and quality of life is often the most important aim.
Consideration of the functional age, quantity versus quality of life and presence of organic or
functional mental health issues should also be considered. In terminal illness the person’s
advance directives should be of primary importance before commencing therapy.
If lifestyle changes or dietary regimens are too rigid or difficult for a patient to adhere to, the
risks to them from severe and unnecessary dietary restrictions can result in decreased food
intake, resulting in unintended weight loss and malnutrition.
The dietitians’ role with the frail older person covers the broad spectrum of clinical interventions and
includes:
- Identifying & assessing malnutrition (risk). Implementing appropriate lifestyle & nutritional
support strategies with the individual, family & staff.
Malnutrition after stroke has been associated with limited response to rehabilitation (Davis ea
(2004)); increased risk of chest infections due to reduced respiratory muscle function (Arora &
Rochester (1982)); apathy, depression, fatigue and loss of motivation (Keys ea (1950)) leading to
lack of willingness to participate in these programmes (Nip et al (2011)). It was found that
dietary energy intake predicts rehabilitation outcomes and post-stroke nutritional support should
be prioritised to ensure optimal recovery.
- Assessing and diagnosing nutrition-related problems for the prescription of nutrition therapy and
calculating nutritional requirements for the prescription of oral nutritional supplements, enteral
tube feeding and parenteral nutrition; co-ordinating tube feeding arrangements for patient
/family /carer.
- Working in collaboration with all members of the health and social care team, such as linking
with speech and language therapy in the management of dysphagia, or with physiotherapy in the
management of physical activity (e.g. preventing falling and sarcopenia).
- Providing nutritional advice to catering services on analysis and development of menus and
therapeutic diets.
- Educating health care professionals on the topic of malnutrition and its relationship with frailty,
and the role of the health care professionals regarding the prevention and treatment of
malnutrition (risk).
- Educating and supporting patient, family/carers to maintain nutritional status; developing a
client-focused nutritional care plan; implementing eating/mealtime strategies for cognitively
impaired; advising on lifestyle/social factors which impact on nutritional intake.
- Promoting and implementing evidence based practice with healthcare professionals, resulting in
positive outcomes for patients and health service resources.
- Malnutrition in >65 years is 43% in hospitals and 42% in residential facilities in Ireland
(BAPEN NSW (2010)). Implementation of nutritional screening tools & referral pathways
are recommended.
- Dietetic interventions with healthcare professionals results in more appropriate
prescribing practices and a 14.5% reduction in prescribing of oral nutritional supplements
(Kennelly ea (2011)).
- Expanding nurses’ role to replace gastrostomy tubes in residential care has shown
reduction in acute hospital admissions (HSE Midlands (2005)).
- Following-up and evaluating the effectiveness of nutrition therapy regularly.
Briefing Paper Older Adults
Revision June 2013
7 of 15
EFAD receives funding from the Executive Agency for Health and Consumers, under
the framework of the Health Programme. Sole responsibility for the content of this
briefing lies with EFAD and the Executive Agency is not responsible for any use that
may be made of the information contained therein.
-
Documenting actions according to relevant requirements and procedures
- Research level
The dietitian has an important role in research of nutrition in ageing. Research to expand the
knowledge about how to assess, diagnose and treat nutrition-related conditions in the older adults is
very useful. e.g. understanding the relationship between behavioural aspects of dementia and how
this can impact on nutritional status is currently being researched and will be of particular
significance for health care services and policy development (McKeon, Ireland - pending publication).
At an academic level, dietitians can contribute to the inclusion of modules on nutrition for the older
adult in nursing and medical training; develop continuing education programmes for professional
colleagues and support student training programmes in the specialism of older adults.
-
Administrative level
Nutrition therapy in older adults care should be patient-focused and may therefore include
addressing meal times and modification of mealtimes, oral nutrition supplements and/or vitamin
and mineral supplements, dietary fortification (energy and /or protein) and texture modification.
When planning nutritional care for older adults it is essential to respect their autonomy and take
ethical factors into account in order to achieve optimal quality of life.
Overview.
Dietitians play a critical role in developing national nutritional recommendations and advising on
incorporating these into menu policy in acute hospitals & community residential services.
Food served in care environments for older adults should not only meet the nutritional
requirements of older people, but also the sensory requirements, as the sensory appreciation of
a meal often determines its consumption.
It is therefore important to consider the environment as well as the menu composition (including
seasonal variations), the quality of ingredients (including spices, herbs and seasoning), food
preparation techniques, cooking time and cooking temperature in order to maximise the eating
experience.
Menus should provide a variety of textures, colours and flavours and should be adapted to suit
requirements for modified diets. Familiar foods tend to be more acceptable to older people,
however, since food habits are becoming more international, other choices may also be
welcome.
The particular preferences and dislikes of the individual, together with the need for adapted
cutlery or assistance in eating and drinking, should be documented and respected.
Individuals should be encouraged to maintain control of their food intake e.g., to choose and
serve their own food with or without assistance. Special attention should be given to mealtimes,
particularly with respect to:
- Meals and mealtimes
- Is there enough time to eat?
Briefing Paper Older Adults
Revision June 2013
8 of 15
EFAD receives funding from the Executive Agency for Health and Consumers, under
the framework of the Health Programme. Sole responsibility for the content of this
briefing lies with EFAD and the Executive Agency is not responsible for any use that
may be made of the information contained therein.
- Designated times of main meals and snacks; is there sufficient time between meals
throughout the course of the day?
- The length of time between the last meal at night and breakfast the following day; is
this too long e.g. 10-12 hours.
- Snacks and drinks; are snacks and fluids available between scheduled meal times?
- Is the temperature of the meal appropriate?
- Modified diets; are all required dietary modifications (texture, consistence, ready to
eat fruit, etc) available?
- Protected mealtimes and snacks; are designated times protected for meals and
snacks?
- Autonomy; are people in a position to choose with whom, when, where (dining room
or own room) and what they eat?
- Monitoring; is there anyone who can check/control the appropriate fluid and food
intake and the chewing and swallowing capacity of the person?
- Variation; is there enough variety for individuals in long-term care? Pictorial menus
should be available for patients with communication difficulties.
- Eating environment
- Dining area; is the dining area clean, calm, comfortable, pleasant and, if necessary,
functionally adapted?
- Dining table; is the dining table clean, set appropriately, inviting?
- Eating position; are individuals seated and positioned appropriately in order to enjoy
their meal comfortably and safely?
- Assistance; is trained assistance available if required?
- Presentation; are meals appetising, of correct temperature and portion size?
- Accessibility; are crockery, cutlery and packaging appropriate for the individual?
- Attitude; are personnel attentive, have meals been described before serving, do
personnel discuss personal issues at mealtimes?
Food safety is of particular concern as older adults are very vulnerable to the effects of food
poisoning due to the high risk of immune-depression in this age group.
In some countries, dietitians are involved in the prevention and control of foodborne diseases
through providing appropriate food safety education and training to carers and older adults,
Dietitians are often involved in the identification and reporting of food safety issues to the
appropriate authorities.
-
Evaluator level
The role of the dietitian as a quality reviewer/evaluator is essential in closing the circle of dietetic
management in older adults care. Whether it is in a strategic, educational, clinical or
administrative role, the dietitian has a responsibility to evaluate the effectiveness of their
actions. The use of audit and research may be helpful in this process.
Dietetic objectives in all roles should be developed according to the SMART principle, i.e.,
Specific, Measurable, Achievable, Relevant, Timely. This provides the framework and timescale
by which dietetic outcomes may be evaluated. (Model & process for nutrition and dietetic
practice BDA 2012)
Briefing Paper Older Adults
Revision June 2013
9 of 15
EFAD receives funding from the Executive Agency for Health and Consumers, under
the framework of the Health Programme. Sole responsibility for the content of this
briefing lies with EFAD and the Executive Agency is not responsible for any use that
may be made of the information contained therein.
The findings of these evaluations are of immense benefit in the future strategic planning of the
role of dietetics within older adults care.
Older adults are at a particular risk of undernutrition if they are not able to prepare a main meal
independently or don’t receive 'meals on wheels'. It is the dietitians' responsibility to detect
nutritional problems and act upon them appropriately4. (Ref Malnutrition Task Group, BDA May
2013)
Nutritional Screening
Nutritional screening tools for the older adult population (MAG, MNA, MUST, SGA, NuRAS,
SNAQrc, SNAQ65+ or NRI) should consider factors like BMI, recent weight loss, skin condition,
respiratory function, dementia, nausea, and much more. In some cases, skinfold thickness, arm
and calf circumference and grip strength measurements may be measured. These methods
generally need an experienced assessor to measure correctly. Furthermore, it is also argued that
nutritional screening should be done routinely.
Nutritional Assessment
The model and process for nutrition and dietetic practice (BDA July 2012) suggests following the
‘A,B,C,D,E’ (Anthropometric, Biochemistry, Clinical Findings, Dietary Intake and Environment )
pathway of assessment
The goal of nutritional assessment is to identify the presence, nature and extent of impaired
nutritional status of any type: obesity or, perhaps more often among old people, undernutrition.
Nutritional assessment evaluates different data related to dietary intake and/or body
composition in order to develop a plan of care that will help improve the nutritional status.
For this it is advisable to differentiate between routine screening done by nurses or doctors and
nutritional assessment performed by the dietitian.
It is important to have policies on nutrition and hydration, followed by relevant procedures and
protocols. Decisions on when it is appropriate to stop treatment but continue to keep the patient
comfortable should be guided by protocol.
Conclusion
Dietitians have the potential to operate at all levels of care: strategic, educational & clinical. They can
influence healthcare practices and be instrumental in developing and advocating policy change i.e.
nutrition screening initiatives. Their influence within the nutrition industry, in promoting health
education activities and improving services to older people is invaluable. Finally, their input within
the multidisciplinary situation is essential, providing an expert opinion on nutrition in complicated
clinical situations.
References
- Arvantitakis M., P. Coppen, L Doughan, A Van Gossum (2009) Nutrition in care homes and home
care: Recommendations, Clinical Nutrition 2009; 28(5):492-496.
4
When stops treatment and is comforting appropriate?
Briefing Paper Older Adults
Revision June 2013
10 of 15
EFAD receives funding from the Executive Agency for Health and Consumers, under
the framework of the Health Programme. Sole responsibility for the content of this
briefing lies with EFAD and the Executive Agency is not responsible for any use that
may be made of the information contained therein.
-
-
-
-
Baeyens, JP, A healthy appetite, Medical and health research, Public Service Review on the
European Union, 353-354, 2008. http://www.european-nutrition.org/images/uploads/pub-pdfs/pdf_pdf_57.pdf
Bauer JM, D Volkert, R Wirth et al. Diagnostik der mangelernahrung des alteren menschen, Dtsch
Med Wochenschr 2006;131(5):223-227.
Becker, H., ‘Generaties en hun kansen’, Amsterdam, Meulenhof, 1993.
BDA 2012, ‘Model and process for nutrition and dietetic practice’
Caroline Walker Trust, ‘Eating well for older people: practical and nutritional guidelines for food
in residential and nursing homes and for community meals.’ Report of an expert working group.
Caroline Walker Trust, London, 1995.
Chodzko-Zajko WJ, DN Proctor, MA Fiatarone Singh, CT Minson, CR Nigg, GJ Salem and JS Skinner
(2009) Position Stand Exercise and Physical Activity for Older Adults, ACSM.
Christensen et al. Ageing populations: the challenges ahead. Lancet 2009 3;374(9696):1196-1208
Copeman, J., ‘Nutritional care for older people: a guide to good practice’, Age Concern England,
London, 1999.
Dunstan DW, Kingwell BA, Larsen R, et al. Breaking Up Prolonged Sitting Reduces Postprandial
Glucose and Insulin Responses. Diabetes Care. May 1, 2012 2012;35(5):976-983.
Dunstan D ON. New exercise prescription: Don't just sit there: stand up and move more, more
often: comment on 'sitting time and all-cause mortality risk in 222 497 Australian adults'.
Archives of Internal Medicine 2012;172(6):500-501.
Dutch malnutrition steering group (2012) Guideline screening and treatment of malnutrition.
http://www.fightmalnutrition.eu/fileadmin/content/fight_malnutrition/methodology/Guideline_Screening_and_Treatment_of_Maln
utrition_English_July_2012.doc
-
ENHA, The Prague declaration, a call for action to fight malnutrition in Europe, 2007.
http://www.european-nutrition.org/images/uploads/pdf_pdf_43_2.pdf
-
EU, The European Innovation Partnership on Active and Healthy Ageing strategic plan, 2011.
http://ec.europa.eu/research/innovation-union/pdf/active-healthy-ageing/steering-group/implementation_plan.pdf
-
EUFIC (2003) Food safety and the elderly. FOOD TODAY 11/2003. European Food Information
Council http://www.eufic.org/article/en/artid/food-safety-elderly/
EUROSTAT, Active ageing and solidarity between generations - A statistical portrait of the
European Union 2012, 2011. (http://epp.eurostat.ec.europa.eu/cache/ITY_OFFPUB/KS-EP-11-001/EN/KS-EP-11-001EN.PDF)
-
-
Goeminne PC, EH De Wit, C Burtin, Y Valcke (2012) Higher food intake and appreciation with a
new food delivery system in a Belgian hospital. Meals on Wheels, a bedside meal approach: A
prospective cohort trial, Appetite 59(1): 108-116.
Guigoz Y, The Mini Nutritional Assessment (MNA): review of the literature - what does it tell us? J
Nutr Health Ageing 2006; 10(6) 466-485.
Haute Autorité de Santé (2007), Stratégie de prise en charge en cas de dénutrition protéinoénergétique chez la personne âgée, HAS. (http://www.has-sante.fr/portail/jcms/c_546836/strategie-de-prise-encharge-en-cas-de-denutrition-proteino-energetique-chez-la-personne-agee?xtmc=&xtcr=2)
-
-
-
Healthy Ageing: How Changes in Sensory Physiology, Sensory Psychology and Socio-Cognitive
Factors Influence Food Choice (http://healthsense.ucc.ie)
Isenring EA, M Banks, M Ferguson, JD Bauer, Beyond malnutrition screening: appropriate
methods to guide nutrition care for aged care residents, J Acad Nutr 2012;112(3):376-381.
Jyvakorpi S, Puranen T, Pitkala KH, Suominen MH. (2012) Nutritional treatment of aged
individuals with Alzheimer disease living at home with their spouses: study protocol for a
randomized controlled trial. Trials. 2012;13:66.
Kaiser MJ, JM Bauer, C Ramsch et al, Validation of the Mini Nutritional Assessment Short-Form
(MNA-SF): a practical tool for identification of nutritional status, J Nutr Health Ageing 2009;13(9):
782-788.
Keep fit for life. Meeting the nutritional needs of older persons. Geneva, WHO, 2002.
Briefing Paper Older Adults
Revision June 2013
11 of 15
EFAD receives funding from the Executive Agency for Health and Consumers, under
the framework of the Health Programme. Sole responsibility for the content of this
briefing lies with EFAD and the Executive Agency is not responsible for any use that
may be made of the information contained therein.
-
-
-
-
Kendall PA et al. Food Safety Guidance for Older Adults. Clin Infect Dis. (2006) 42 (9): 1298-1304.
Kennelly S, NP Kennedy, CA Corish, G Flanagan-Rughoobur, C Glennon Slattery, S Sugrue (2011)
Sustained benefits of a community dietetics intervention designed to improve oral nutritional
supplement prescribing practices. J Hum Nutr Diet, 24, 496-504.
Kennelly S, NP Kennedy, G Flanagan-Rughoobur, C Glennon Slattery, S Sugrue (2010) An
evaluation of a community dietetics intervention on the management of malnutrition for healthcare professionals. J Hum Nutr Diet.
Kennelly S, NP Kennedy, G Flanagan Rughoobur, C Glennon Slattery, S Sugrue (2009) The use of
oral nutritional supplements in an Irish community setting. J Hum Nutr Diet, 22, 511-520.
Kondrup J, SP Allison, M Elia, B Vellas and M Plauth (2003) ESPEN guidelines for nutrition
screening 2002, Clinical Nutrition 22(4): 415-421.
Lennard-Jones, J. E., Arrowsmith, H., Davidson, C., Denham, A. F., Micklewright, A. (1995),
Screening by Nurses and Junior Doctors to detect malnutrition when patients are first assessed in
the hospital, Clinical Nutrition,14:336-40.
Loane D, G Flanagan, A de Siún, E Mc Namara, S Kenny (2004) Nutrition in the community - an
exploratory study of oral nutritional supplements in a health board area in Ireland. J Hum Nutr
Dietet, 17, 257-266.
-
The Malnutrition Task Force (2013) Prevention and Early Intervention of Malnutrition in Later Life.
Best Practice Principles and Implementation Guide: A Local Community Approach
-
Manning F, K Harris, R Duncan, K Walton, J Bracks, L Larby, L Vari, K Jukkola, J Bell, M Chan, M
Batterham (2012), Additional feeding assistance improves the energy and protein intakes of
hospitalised elderly patients. A health services evaluation, Appetite, 59(2), 471-477.
Michel JP. Nutrition-Ageing and Longevity( 2009) Institute Danone
Nutrition for older persons. Ageing and nutrition: a growing global challenge
-
http://www.who.int/nutrition/topics/olderpersons/en/index.html
-
Persson et al. Chapter 5. Elderly People’s Health - 65 and After. Scand J Public Health 2001; 29
(Suppl 58): 117-131
Niedert KC; American Dietetic Association. Position of the American Dietetic Association:
liberalization of the diet prescription improves quality of life for older adults in long-term care. J
Am Diet Assoc [serial online]. 2005;105:1955-1965.
http://eatright.org/cps/rde/xchg/ada/hs.xsl/advocacy_adar0902_ENU_HTML.htm.
-
-
Ritchie CS, JL Locher, DL Roth, T Mc Vie, P. Sawyer and R Allman (2008) Unintentional weight loss
predicts decline in activities of daily living function and life-space mobility over 4 years among
community-dwelling older adults, Journal of Gerontology: Medical Sciences, 2008; 63A1: 67-75.
Rizzuto D, N Orsini, C Qiu, H-X Wang, L Fratiglion, Lifestyle, social factors, and survival after age
75: population based study, BMJ 2012;345:e5568.
www.bmj.com/highwire/filestream/600213/field_highwire_article_pdf/0/bmj.e5568.full.pdf
-
-
Skates JJ & PS Anthony, Identifying geriatric malnutrition in nursing practice: the mini nutritional
Assessment (MNA) - an evidence based screening tool, J Gerontol Nurs 2012.
Skipper A, M Ferguson, K Thompson, VH Castellanos, J Porcari, Nutrition screening tools : an
analysis of the evidence, JPEN J Parenter Enteral Nutr 2012:36(3):292-298.
Suominen MH, Kivisto S, Pitkala KH. (2007) The effects of nutrition education on professionals’
practice and further to the nutrition of aged nursing home residents. Eur J Clin Nutr. 2007;61:
1226-1232.
Suominen MH, Finne-Soveri H, Hakala P, Jyväkorpi SK, Männistö S, Pitkälä KH, Soini H, SarlioLähteenkorva S. (2012) Nutritional Guidelines for Older People in Finland. Public Health Nutrition
Tayside NHS board, Nutrition guidelines for older people, 2002.
http://www.thpc.scot.nhs.uk/wordfiles/OlderPeople.pdf
-
Thomas, A.J., Nutrition and the Elderly. Nursing Times - Nutrition in Practice 10, 1998.
Van der Mark et al. (2009) Obesity Facts; 2:74-79.
Briefing Paper Older Adults
Revision June 2013
12 of 15
EFAD receives funding from the Executive Agency for Health and Consumers, under
the framework of the Health Programme. Sole responsibility for the content of this
briefing lies with EFAD and the Executive Agency is not responsible for any use that
may be made of the information contained therein.
-
Veurinckx, R. Senioren marketing, Memori symposium ‘Het merk gezondheid’, 2008.
Wadden et al.(2009) Obesity (Silver Spring) 2011 October ; 19(10): 1987-1998.
Webb, G.P., Coperman, J., The Nutrition of Older Adults. London: Arnold and Age Concern, 1996.
World Population Ageing 1950-2050. Department Of Economic And Social Affairs population
Division United Nations ST/ESA/SER.A/207, New York, 2001
http://www.who.int/topics/ageing/en/index.html
-
Ziegler F & P Dèchelotte (2009) L’èvaluation nutritionelle chez le sujet âgé en 2008 Nutrition
Clinique et Metabolisme 2009 ;23(3) : 124-128.
Addendum
Routine nutritional assessment and nutritional risk screening approaches in older adults.
- Dietitians should take a lead role in the introduction of routine nutritional screening in hospitals,
care homes and community settings. Most patients have to have a nutritional assessment within
the first 24 hours of the admission. If the patient is not at risk on admission, no action is
necessary, except rescreening every week in hospital or every 3 months in care homes. This is
done to prevent malnutrition/undernutrition during the stay.
Simple measures such as monitoring weight are vital to aid early identification of potential
problems and allow appropriate action to be taken. Chair scales with a footrest should be
available or scales suitable for wheelchairs.
The use of a validated nutrition screening tool appropriate to the elderly and approved by a
dietitian is recommended.
An example of a simple screening tool is the ‘4 question approach’ (Lennard Jones et al (1995))
using the following:
- Have you unintentionally lost weight recently?
- Have you been eating less than usual? Food intake/waste
- What is your normal weight?
- How tall are you?
- Laboratory tests, which measure the concentration of a particular nutrient or variable affected
by a particular nutrient in a tissue, are indicators of undernutrition. For example serum
haemoglobin, ferritin, albumin, vitamin D, vitamin B12, vitamin B1, TLC, C-reactive-protein, BSE,
etc… can be measured.
Best practices in counselling methodologies by European dietitians
- Techniques to help improve motivation and behavioural change
- Motivational interviewing
- Situational coaching
- Discount rates (http://painconsortium.nih.gov/symptomresearch/chapter_4)
- Mindful eating
- Workshops
- Healthy nutrition
- Menu planning (paying attention to budget and cultural differences)
- How to read food labels
- Healthy shopping
- Cooking classes
- Visualization tools used in education
- Pictures of food portions
Briefing Paper Older Adults
Revision June 2013
13 of 15
EFAD receives funding from the Executive Agency for Health and Consumers, under
the framework of the Health Programme. Sole responsibility for the content of this
briefing lies with EFAD and the Executive Agency is not responsible for any use that
may be made of the information contained therein.
-
-
- Food composition tables
Tools that are helpful in promoting physical activity
- A pedometer (e.g. Digiwalker)
- An accelerometer
Infotainment games
- Quartet
- Quiz
Further Reading
1. Mini Nutritional Assessment (MNA)
- Guigoz Y, Vellas B, Garry PJ. Mini Nutritional Assessment: a practical assessment tool for grading
the nutritional state of elderly patients. Facts and Research in Gerontology 1994:4: suppl 2,15-59.
- Guigoz Y, Vellas B, Garry PJ. Assessing the nutritional status of the elderly: The Mini Nutritional
Assessment as part of the geriatric evaluation. Nutrition Review 1996; 54(1): 559-565.
-
http://www.mna-elderly.com/
2. Nutrition Risk Assessment Scale (NuRAS)
Nikolaus T, Bac M, Siezen S, Volkert D, Oster P, Schlierf G. Assessment of nutritional risk in the
elderly. Annuals of Nutrition and Metabolism 1995; 39: 340-345.
3. Nutritional Risk Index (NRI)
- Wolinsky FD, Coe RM, Chavex MN, Prendergast JM, Miller DK. Further assessment of the
reliability and validity of a nutritional risk index. Journal of Community Health 1989; 14(3): 125135.
- Wolinsky FD, Coe RM, McIntosh WA, Kubena KS, Prendergast JM, Chavez MN, Miller DJ, Roeis JC,
Landmann WA. Progress in the development of a nutrition risk index. Journal of Nutrition 1990;
120: Supply 11 1549-1553.
4. MAG Screening Tool for Adults at Risk of Malnutrition
www.bapen.org.uk
5. SNAQrc and SNAQ65+
- Wijnhoven HA, Schilp J, van Bokhorst-de van der Schueren MA, de Vet HC, Kruizenga HM, Deeg DJ,
Ferrucci L, Visser M. Development and validation of criteria for determining undernutrition in
community-dwelling older men and women: The Short Nutritional Assessment Questionnaire 65+.
Clin Nutr. 2012 Jun;31(3):351-8. Epub 2011 Nov 25.
- Kruizenga HM, de Vet HC, Van Marissing CM, Stassen EE, Strijk JE, Van Bokhorst-Van der Schueren
MA, Horman JC, Schols JM, Van Binsbergen JJ, Eliens A, Knol DL, Visser M, The SNAQ (RC), an easy
traffic light system as a first step in the recognition of undernutrition in residential care. J Nutr
Health Ageing. 2010 Feb;14(2):83-9.
6. EFAD position paper on the role of the dietitian in the prevention and management of malnutrition
in adults
-
How to promote active ageing in Europe EU support to local and regional actors. The European
Commission, The Committee of the Regions, AGE Platform Europe, 2011
World Population Ageing 2009. Department of Economic and Social Affairs Population Division
ESA/P/WP/212 United Nations New York, 2009
Population structure and ageing. EUROPOP2010- Convergence scenario, national level.
EUROSTAT (the statistical office of the European Union)
European Parliament Fact Sheets http://www.europarl.europa.eu/facts_2004/4_8_8_en.htm
-
http://www.centerforgastrology.com/Content/resources/20110525%20Towards%20a%20global%20new%20deal%20in%20food.pdf
http://ec.europe.eu/active-healthy-ageing
-
Briefing Paper Older Adults
Revision June 2013
14 of 15
EFAD receives funding from the Executive Agency for Health and Consumers, under
the framework of the Health Programme. Sole responsibility for the content of this
briefing lies with EFAD and the Executive Agency is not responsible for any use that
may be made of the information contained therein.
-
http://www.european-nutrition.org/
http://www.fightmalnutrition.eu/malnutrition/screening-tools/
https://webgate.ec.europa.eu/sanco/heidi/index.php/Heidi/Population_group-specific_health/Elderly
http://www.stuurgroepondervoeding.nl/
Acknowledgements
EFAD would like to thank Elisabet Rothenberg (Sahlgrenska University Hospital), Elizabeth Archer
(British Dietetic Association (BDA)) Grainne Flanagan (Irish Nutrition and Dietetic Institute (INDI)),
Margaret Page Rodebjer (Tiohundra), Emine Aksoydan (Baskent University), Frode Slinde (University
of Gothenburg), Merja Suominen (Society for Memory Disorders Expertise), Anne Marie Favreau
(AFDN) Expert commission on clincial nutrition and expert commission on community and public
health nutrition of the Portuguese Association of Nutritionists, Norisa Cebola and Vania Costa
(Portuguese Dietetic Association), Naomi Trostler (Hebrew University of Jerusalem), Osnat Stone
(Association of Nutritionists and Dietitians in Israel - ATID), Karin Kouwen-oord (Zorgbalans), Wineke
Remijnse (NVD), Kinga Bartha (Hungarian Dietetic Association - MDOSZ), Danish Diet and Nutrition
Association, Britt R. Sørø and Arnt R. Steffensen (The Norwegian Association of Dietitians), Amalia
Tsagari and Catherine Karakike (The Hellenic Association of Dietitians), Claudine Mertens (ANDL), Dr.
Harriet Jager-Wittenaar (Hanze University of Applied Sciences), Anne de Looy (Plymouth University),
Diane Watson (NHS North Lancashire), Neslişah Rakıcıoğlu (Haceteppe University Ankara), Hilda
Griffin (St Mary's Hospital Dublin) and Maria Romeu Quesada (AEDN) for their constructive
contribution.
Briefing Paper Older Adults
Revision June 2013
15 of 15
EFAD receives funding from the Executive Agency for Health and Consumers, under
the framework of the Health Programme. Sole responsibility for the content of this
briefing lies with EFAD and the Executive Agency is not responsible for any use that
may be made of the information contained therein.