Nutrition and hydration

Screen all patients over 65 years within 24 hours of hospital admission. We should consider those patients who require surgery, as routine fasting for prolonged periods can lead to serious complications in people who are malnourished.⁷

Use a validated screening tools such as the following.

The Malnutrition Screening Tool (MST)

This simple three-step tool assesses recent weight and appetite loss and is the most widely used nutritional screening tool in Australian hospitals. It can be used by staff, family or friends. It asks two questions, gives a score to indicate risk of malnutrition, and recommends steps for follow-up⁸.

The Mini Nutrition Assessment (MNA)

This assessment was developed for people over 65 years. It explores 18 items relating to the patient’s medical, lifestyle, dietary, anthropometrical and psychosocial factors⁸. The score indicates patients at risk of or suffering from malnutrition.

The Mini Nutrition Assessment Short Form (MNA-SF)

This shorter version of the MNA includes a ‘two step nutrition screen’ that identifies patients with under-nutrition and patients who should be referred to a dietitian for further assessment. This form is useful for patients who are not suspected to be at risk of malnutrition.

The Malnutrition Universal Screening Tool (MUST)

This five-step screening tool is simple to use and can be used by all care workers. It focuses on Body Mass Index (BMI), unexplained weight loss and acute illness effect and can also be used to detect obesity. This tool provides management guidelines to assist with developing a care plan.⁹

A medical history should explore the following issues.

Medication

• What medications are being taken? Some can cause nausea or affect appetite.
• Be aware that if the patient is not eating and drinking well, they may not metabolise medications effectively.

Continence

• Incontinence and constipation can impact on nutrition. For example, patients who are constipated are at risk of developing delirium.
• Some patients may drink less in fear of using the toilet regularly.

Other conditions or impairments

• Arthritis or vision impairment can affect the person’s ability to open food packages and feed themselves.
• Pain and nausea may reduce appetite.
• Stroke and Parkinson’s disease can affect a person’s food consumption and ability to safely swallow and feed themselves.
• Cognitive impairment, such as dementia or delirium, can cause problems with eating and drinking, especially in an unfamiliar environment.
• Social isolation can impair a person’s ability to access adequate healthy food. For example, a change in home circumstances or lack of social or physical support can make it difficult for someone to get to shops.
• Lifestyle diseases, such as diabetes, hypertension, alcoholism and smoking, can impact on nutrition and vitamin absorption.

Dehydration is very common in older patients, and if not addressed can lead to serious complications including prolonged recovery from illness and surgery, and increased mortality. Dehydration also increases the risk of serious medical complications such as delirium, urinary tract infections, medication toxicity, decreased muscle strength and falls.^10,11

Be aware of the signs of dehydration in patients who are malnourished as 70 per cent of our daily fluid requirements can be obtained from the diet.¹⁰ Signs of dehydration include:

• postural hypotension – dizziness from the sit to standing position
• decreased urinary output
• dark urine colour
• dryness of the mouth
• poor skin turgor
• sunken eyes^10,12
• headaches
• fatigue
• constipation.

Asking the patient (and their family and carers) what matters to them enables us to tailor treatments to suit them. Ask if they have:

• noticed any changes in weight
• noticed changes in appetite
• specific food preferences and intolerances
• lost teeth, have mouth sores, if their dentures fit poorly or they have problems with chewing and swallowing
• been depressed or have experienced other changes to their mental and cognitive health
• people and services that support them at home, such as Meals on Wheels or help getting to the shops.

To gauge an older patient’s nutritional health, assessment should include the following issues:

Weight and height

Calculating the patient’s BMI provides a baseline to monitor their weight throughout their stay. A BMI of around 27.5 generally indicates better outcomes for older people¹³.

Vitamin deficiencies

The following are signs of vitamin deficiencies.

• Dry lips and dry scaly skin can indicate poor hydration and nutrient deficiency.
• Swollen, bleeding gums or a sore red swollen tongue (glossitis) can indicate vitamin C and or Vitamin B deficiency or gum disease.
• Pale skin, breathlessness on exertion, fatigue and dizziness can indicate iron deficiency.
• Pressure injuries are common in older people with poor nutrition and can indicate a need to promptly increase vitamin C and protein.
• Regular respiratory infections, such as colds, flu or COPD can indicate a compromised immune system and nutrient deficiencies.
• Poor mobility and balance, being bed bound or unable to sit upright to eat and drink – assist the patient with positioning and refer to a physiotherapist or occupational therapist.

Laboratory data

Take blood tests and check for deficiencies such as iron (Fe), vitamin D, calcium, B vitamins and zinc. Vitamin D and calcium are important for bone health, vitamin D also helps protect the immune system, low B levels are associated with delirium and dementia and low zinc levels can affect sense of taste and reduce appetite.^14,15

Work with a dietitian

If you think a patient is malnourished or at risk of malnutrition or dehydration, refer to a dietitian and ask the medical team for a comprehensive assessment. The dietitian may prescribe a specialised diet or supplements.

Food is as important as medicine. Nutrition should be a priority for everyone - the patient, their family and carers, the healthcare professionals and food service providers.

• Become ‘food aware’. Food and drink are as important as medication.
• Be alert that older people who are fasting for procedures, such as surgery, are particularly at risk. Follow local procedures and enlist the support from a dietitian to minimise poor outcomes.
• Follow the dietitian’s recommendations on food modification or special diets.
• Document treatment goals clearly, familiarise yourself with diet codes and ensure all staff can access this information.
• Consult with the dietitian to determine how and when foods will be fortified, for example with protein powders, glucose, skim milk powder and cream.
• Ask the speech pathologist for advice on food modification for patients with swallowing issues.
• Discuss with the dietitian introducing high calorie and high protein foods that can assist a patient increase their weight.
• Involve the patient in setting weight and calorie goals. Placing the patient at the centre of their care will assist in achieving clinical outcomes.
• Ask the patient what foods they like to eat. If the patient’s family wants to bring meals from home, advise them on choosing nutrient-dense foods.
• Check if meals are culturally appropriate.
• Order the right meal for the right person and enter the correct diet codes to avoid adverse events such as aspiration or allergic reactions.
• Work as a team to monitor food waste after meals (food charts can be used to correctly monitor food and drink consumption), this is a good indication of those needing assistance.
• Introduce programs, such as protected meal times which minimises disruptions to meal times or use identifiers such as red trays or domes to identify which patients need assistance during meals. Use volunteer programs to optimise intake.
• If space permits, consider establishing communal dining arrangements, to encourage socialising, combat loneliness and potentially improve dietary intake while in hospital.
• Consider using ward champions to promote best practice on your ward.

Ask every patient if they need assistance to eat and drink and respond to their needs.³

• Encourage communal dining where possible.
• Engage nursing staff, volunteers and family members to assist at meal times.
• Encourage patients to use the toilet prior to meals.
• If the patient can’t sit out of bed, use pillows to help them sit upright.
• Adjust the bed table so the tray is within reach.
• Clear the tray table of clutter or hazards.
• Remove or reduce distractions, such as bright lights, offensive smells such as urine bottles, and sounds especially for patients with delirium or dementia.
• Encourage people to wash their hands or provide hand hygiene gel prior to meals.
• Provide every patient with a serviette, cutlery and water.
• Put the utensils in front of the patient, check they can use them, and provide help if needed.
• Help patients open food packages.
• Monitor food waste. If a patient regularly leaves trays of uneaten food or untouched drinks, investigate.

Also you know how busy they are [hospital staff] and you don’t want to worry them - you’re not going ring the bell to ask them to open your fruit salad - so you just don’t do it. So either you don’t eat it or you wait for someone. Or if you’ve got someone from your family coming in that’s fine.
- Patient

Stimulating appetite and helping people eat and drink can make a difference.

• Help patients fill out their meal order form and educate them about good choices.
• Encourage the patient to sit out of bed for meals or eat in the communal dining area.
• Encourage patients to eat at meal times or to eat small meals regularly when they are most hungry and to indulge in their favourite foods.
• Offer patients snacks to keep them interested in food. Remember, the longer a patient goes without food for the more likely they will not feel hungry.
• Encourage the patient to keep hydrated. Offer drinks regularly.
• Acknowledge that a patient may be more motivated and interested to eat food they are used to. Engage family members to provide meals where possible.

Some medications can impact on appetite, cause dehydration and nausea, and contribute to under-nutrition.

• Ask the pharmacist to review the patient’s medication, look at possible side effects and drug interactions.
• Patients with swallowing problems may need assistance with taking medications and supplements. Some tablets may need to be given with food for ease of swallowing. Consult with the speech pathologist if you are concerned.

• If a patient is feeling depressed, consider what could improve their mood, for example, allow them to eat in a social environment – invite family and friends to provide company.

Encourage patients to be active as this can stimulate appetite and enhance muscular strength and reduce the risk of pressure injuries.

• Encourage the patients to take regular breaks from their bed or chair and mobilise around the ward.
• Encourage them to have time away from the ward, if possible, outside. Sunshine helps lift a person’s mood and provides Vitamin D.
• Refer to a physiotherapist if the person has mobility problems.

• Older adults need more protein in their diet than younger people, to help the body recover from illness, maintain functionality, assist with the inflammatory processes that occur with many diseases, and to be used as energy by the body when carbohydrate intake in inadequate.
• It is vital that people over 65 years maintain lean muscle mass and function and their protein intake should be at least 1.0 to 1.2 grams of protein per kilogram per day.¹⁶ A dietitian can make recommendations on how to incorporate protein through foods or supplements, taking into account each patient’s needs and history.
• High-protein foods include cheese, yoghurt and dairy products; soy products including soy milk, tofu and tempeh; meat such as chicken, red beef and fish; pulses, lentils and beans; whole grains; eggs; nuts and seeds.
• Familiarise yourself with the benefits of a High Energy High Protein (HEHP) diet and work with a dietitian to prescribe this if necessary.

Nutrient and vitamin supplements can help elderly people achieve good nutrition.

• Ask the dietitian to assist with prescribing supplements. Supplements should be given two hours before meal times.¹⁷
• Some patients may not like the taste of supplements or have difficulty swallowing them. Discuss these concerns and tailor a treatment plan to the individual.
• Swallowing problems will affect a person’s ability to swallow supplements. If the patient has, or is suspected of having, dysphagia, refer them to a speech pathologist for assistance.

Eating in hospital is very different from home; not just what we eat but how we eat.

• Check if the ward can accommodate the family bringing in appropriate foods that might stimulate the patient’s appetite and interest in food.
• Ask food staff if the patient’s food preferences can be met, for example, some cultures eat more of certain foods such as rice or pasta.
• Ask the patient how they like to eat their food, for example, if they like to eat with others arrange for family, friends or volunteers to be there.

1. Visvanathan, R., Nutrition in the Frail Elderly, R. Visvanthan, Editor 2014, Aged & Extended Care Services, The Queen Elizabeth Hospital And Adelaide Geriatrics and Research with Aged Care Centre.

2. Shetty, P. Malnutrition and Undernutrition. 2003. 5.

3. Visvanathan, R., Managing nutrition in the elderly: Grief and depression. Editor 2011: N.H. Science, Victoria, Australia.

4. Kurrle, S., Brodaty, H, Hogarth, R, Physical Comorbidties of Dementia. 2012: Cambridge University Press, New York.

5. El-Sharkawy, AM, Sahota, O, Maughan, RJ, Lobo, DN, The pathophysiology of fluid and electrolyte balance in the older adult surgical patient. Clinical Nutrition 2014. 33(1): p. 7.

6. Ahmed, T., Haboubi, N, Assessment and management of nutrition in older people and its importance to health. Clinical Interventions in Aging 2010. 5: p. 9

7. Daniels, L., Good nutrition for good surgery: clinical and quality of life outcomes. Australian Prescriber, 2003. 26(6).

8. Barker, L., Gout, B, Crowe, T, Hospital malnutrition: prevalence, identification and impact on patients and the healthcare system. Int J Environ Res Public Health, 2011. 8(2): pp. 514-27.

9. Bapen UK, Malnutrition Universal Screening Tool, www.bapen.org.uk

10. Wotton, K., Crannitch, K, Munt, R, Prevalence, risk factors and strategies to prevent dehydration in older adults, Comtemporary Nurse, 2008. 31(1): p. 16.

11. Mentes, J.C, Oral hydration in older adults: greater awareness is needed in preventing, recognizing and treating dehydration. American Journal of Nursing, 2006. 106(6): p. 49.

12. Fortes, M.B., Owen, J.A, Raymond-Barker, P, Bishop, C, Elghenzai, S, Oliver, S.J, Walsh, N.P, Is this elderly patient dehydrated? Diagnostic accuracy of hydration assessment using physical signs, urine and saliva markers. JAMDA, 2015. 16(3).

13. Deakin University. Carrying extra weight could be healthier for older people. 2014; Media Release. Available from: http://www.deakin.edu.au/news/latest-media-releases/2014/carrying-extra-weight-could-be-healthier-for-older-people

14. Hobbins, N., Eat to cheat ageing. 2014: Citrus Press, Northbridge, NSW.

15. Aliani, M., Udenigwe, C, Girgih, A, Pownall, T, Bugera, J, Eskin, M, Zinc deficiency and taste perception in the elderly. Critical Reviews in Food Science and Nutrition, 2013. 53: p. 5.

16. Bauer, J., Biolo, G, Cederholm, T, Cesari, M, Cruz-Jentoft, AJ, Morley, JE, Phillips, S, Sieber, C, Stehle, P, Teta, D, Visvanathan, R, Volpi, E, Boirie, Y, Evidence-based recommendations for the optimal dietary protein intake in older people: A position paper from the PROT-AGE Study Group. JAMDA, 2013. 14: p. 14.

17. Silverbook Australia, Medical care of older persons in residential aged care facilities. 2006: Tthe Royal Australian College of General Practitioners.