Malnutrition in the Older Adult
The establishment of an Ohio prevention commission illustrates how advocacy efforts can be game-changers.
Malnutrition prevalence in the older adult is well recognized, and awareness of the condition continues to grow.1,2 Despite increased awareness, malnutrition remains a significant issue for older adults across the care continuum and also in the community.3
Malnutrition is a leading cause of morbidity and mortality in the older adult. Health care–acquired infections, pressure injuries, falls, worsening lung and heart function, longer hospital stays, and higher overall mortality are known to occur more frequently in malnourished individuals.4-6
Preventing or minimizing malnutrition is of key importance to the older adult and must not be overlooked. Malnutrition, to any degree, can affect older adults' independent living and their aging process, and can worsen the severity of their chronic conditions and disabilities.7
To address malnutrition in the Ohio older adult, a Malnutrition Prevention Commission was established in late 2016 tasked with developing recommendations for reducing the incidence of malnutrition among older Ohioans. These recommendations were to be based on the commission's gathering of information and malnutrition data in those 60 years of age and older.
During the commission's data gathering process, it identified common themes forming the basis for a number of recommendations focused on several areas: education and awareness, data and evaluation, and prevention models using team-based care. The commission's final report provided 16 recommendations to address malnutrition in the Ohio older adult.
The purpose of this brief review is to highlight key recommendations within the Ohio report that can be considered by other states as well as caregivers, clinicians, and all involved in the care of the older adult.
Education and Awareness Recommendations
During its annual MAW, ASPEN offers educational events and activities for clinicians, consumers, and others who are involved in the care of malnourished individuals or those at risk. (See www.nutritioncare.org/maw for further details.) Broadening the malnutrition knowledge base to include those who may be affected and their families can bring greater attention to the issue and lead to earlier intervention with the likelihood of improved outcomes.
Leaders within health care and community settings can easily implement a malnutrition awareness program in their specific practice environments.
An additional recommendation states that the Ohio Department of Aging should offer electronically available evidence-based malnutrition care education tools, materials, and diverse programs for clinicians, patients, families, and caregivers as part of the integration of shared decision making and person-centered care models. These resources can offer opportunities, tools, and programs for raising malnutrition awareness.
Organizations such as ASPEN, the Academy of Nutrition and Dietetics, and the coalition Defeat Malnutrition Today offer toolkits for recognizing malnutrition and addressing it from an interventional perspective (see "Resources" below). Toolkits offer multiple ideas and resources to increase awareness, including creation of a mini awareness campaign with flyers, offering "Lunch and Learn" sessions with experts, and formal CPE sessions during one or more of the scheduled MAW events. Hosting these types of efforts will raise malnutrition awareness well beyond the health care setting.
Data and Evaluation Recommendation
The commission provided a recommendation to address this: Encourage health care providers to adopt clinically relevant malnutrition quality measures in registries and private accountability programs to support effective malnutrition prevention, identification, diagnosis, treatment, and care transitions for older adults. One such program, supported by the Academy of Nutrition and Dietetics, Avalere Health, and other stakeholders, including ASPEN, is the Malnutrition Quality Improvement Initiative (MQii) (see "Resources" sidebar). This program was designed to help organizations improve malnutrition care and, subsequently, achieve improved outcomes.
One component of the MQii incorporates electronic clinical quality measures, which supports national goals to enhance the quality and value of health care delivery. Two facilities that have implemented a quality improvement program have published their results, outlining improved hospital lengths of stay and reduced 30-day readmissions and overall costs of care.9,10
Any quality improvement effort designed and implemented to address malnutrition care in any setting will be of great benefit. Such efforts can identify significant gaps in identification, diagnosis, intervention, and reassessment and their associated processes. (Additional published examples of malnutrition quality improvement programs in both the hospital and community settings are identified in the references.)11-13
Prevention Models: Team-Based Care Recommendations
One of these was to encourage Area Agencies on Aging (AAA) and providers to make greater use and implementation of nutrition counseling and medical nutrition therapy (MNT) for clients who receive home-delivered meals. All states, including Ohio, provide regional aging agencies as established under the Older Americans Act to address the needs of adults 60 and older. Many of these regional agencies offer nutrition services in the form of home-delivered meals (eg, Meals on Wheels) to those at nutritional risk.
Referrals to this service are often made during transition of care from an acute or long term care setting. Nutrition screening and follow-up nutrition assessment and care of those referred to a home meal delivery program is not required and, in many instances, not provided.
In a 2015 nutrition services program process study by the National Resource Center on Nutrition and Aging, of the 199 local service providers who responded to the survey, 52% indicated they performed nutrition screening and assessment, but only 28% outlined the provision of MNT.14 Whether these data reflect lack of funding for screening, assessment and the provision of MNT services for those determined to be malnourished is unknown, but it does demonstrate that improvements in nutrition care processes are needed.
In Ohio, studies have shown that up to 50% of community-dwelling older adults may be malnourished.15 AAA's are the logical choice to provide comprehensive nutrition services to at-risk, home-bound older adults. One approach being piloted in central Ohio is a two-phase program whereby physicians identify high-risk patients who then receive 30 days of home-delivered meals and are screened and assessed by a registered dietitian (RD).
Phase Two involves provision of MNT follow-up for those the RD determines to be malnourished. This program has been designed to align with recent models of reimbursement through the Centers for Medicare & Medicaid Services that emphasize preventive care.16 Development and implementation of programs such as this can provide greater opportunities for older, malnourished adults to receive appropriate and adequate nutrition intervention.
Communication of essential nutrition information during transition of care from one setting to another is often suboptimal.3 As a result, malnourished older adults leaving a care setting—an acute care hospital, for example—may transition to a home setting without a documented malnutrition diagnosis and nutrition care plan. In such instances, the older adults may continue to deteriorate nutritionally, which may affect their ability to stay in their home environments and result in negative clinical outcomes.
This communication gap is addressed by the commission's recommendation that clinicians should educate individuals, caregivers, and providers of nutritional services and products during transition of care, including home-delivered meals, oral nutritional supplements, and food assistance programs. Education of individual patients, their families, and caregivers about the available nutrition resources and services certainly can lead to improved nutrient intakes in older malnourished adults.
The use of oral nutrition supplements to enhance nutrient intake from meals has demonstrated significant outcome benefits and is a recommended intervention by the World Health Organization in its 2017 Integrated Care for Older People Guidelines. The guidelines recommend specific community-level interventions to manage declines in intrinsic capacity and include a section on malnutrition.17
Malnutrition prevalence in the older adult remains an issue and will only continue and escalate as the US adult population 60 years of age and older grows. Addressing malnutrition in this population is critical to reduce health care costs and improve clinical and functional outcomes including an improved quality of life. A state-focused advocacy effort, such as that provided by the Ohio Malnutrition Commission, is one method to raise awareness and address the gaps in nutrition care that ultimately impact the older adult.
— Ainsley Malone, MS, RD, LD, CNSC, FAND, FASPEN, is a nutrition support dietitian at Mt. Carmel West Hospital in Columbus, Ohio, where she's involved in the nutrition care of patients requiring enteral and parenteral nutrition. She's a subject matter expert in malnutrition care and was a member of the Ohio Malnutrition Prevention Commission.
• The American Society of Parenteral and Enteral Nutrition Malnutrition Solution Center: www.nutritioncare.org/guidelines_and_clinical_resources/Malnutrition_Solution_Center
• Defeat Malnutrition Today Resources:
• Malnutrition Quality Improvement Initiative Resources: http://mqii.defeatmalnutrition.today/resources.html
2. Weiss AJ, Fingar KR, Barrett ML, et al; Agency for Healthcare Research and Quality. Statistical brief #210: characteristics of hospital stays involving malnutrition, 2013. https://www.ncbi.nlm.nih.
3. Tappenden KA, Quatrara B, Parkhurst ML, Malone AM, Fanjiang G, Ziegler TR. Critical role of nutrition in improving quality of care: an interdisciplinary call to action to address adult hospital malnutrition. J Acad Nutr Diet. 2013;113(9):1219-1237.
4. Fry DE, Pine M, Jones BL, Meimban RJ. Patient characteristics and the occurrence of never events. Arch Surg. 2010;145(2):148-151.
5. Schneider SM, Veyres P, Pivot X, et al. Malnutrition is an independent factor associated with nosocomial infections. Br J Nutr. 2004;92(1):105-111.
6. Fingar KR, Weiss AJ, Barrett ML, et al; Agency for Healthcare Research and Quality. Statistical brief #218: all-cause readmissions following hospital stays for patients with malnutrition, 2013. https://www.ncbi.nlm.nih.gov/books/NBK410088/pdf/Bookshelf_NBK410088.pdf. Published December 2016.
7. Correia MI, Waitzberg DL. The impact of malnutrition on morbidity, mortality, length of hospital stay and costs evaluated through a multivariate model analysis. Clin Nutr. 2003;22(3):235-239.
8. Braunschweig C, Gomez, S, Sheean PM. Impact of declines in nutritional status on outcomes in adult patients hospitalized for more than 7 days. J Am Diet Assoc. 2000;100(11):1316-1322.
9. Sriram K, Sulo S, VanDerBosch G, et al. A comprehensive nutrition-focused quality improvement program reduces 30-day readmissions and length of stay in hospitalized patients. JPEN J Parenter Enteral Nutr. 2017;41(3):384-391.
10. Meehan A, Loose C, Bell J, Partridge J, Nelson J, Goates S. Health system quality improvement: impact of prompt nutrition care on patient outcomes and health care costs. J Nurs Care Qual. 2016;31(3):217-223.
11. Wadas-Enright M, King A. Early recognition of malnutrition in the older adult: a quality improvement project using a standardized nutritional tool. J Community Health Nurs. 2015;32(1):1-11.
12. Lim SL, Ng SC, Lye J, Loke WC, Ferguson M, Daniels L. Improving the performance of nutrition screening through a series of quality improvement initiatives. Jt Comm J Qual Patient Saf. 2014;40(4):178-186.
13. Chambers R, Bryan J, Jannat-Khah D, Russo E, Merriman L, Gupta R. Evaluating gaps in care of malnourished patients on general medicine floors in an acute care setting [published online April 27, 2018]. Nutr Clin Pract. doi: 10.1002/ncp.10097.
14. Mabli J, Redel N, Cohen R, Panzarella E, Hu M, Carlson B; Mathematica Policy Research. Final report: Process Evaluation of Older Americans Act Title III-C Nutrition Services Program. https://www.acl.gov/sites/default/files/programs/2017-02/NSP-Process-Evaluation-Report.pdf. Published September 30, 2015.
15. Lloyd JL; Meals on Wheels America. Hunger in older adults: challenges and opportunities for the aging services network. http://www.mealsonwheelsamerica.org/docs/default-source/research/
16. Ohio Department of Health. Malnutrition Prevention Commission. https://docs.wixstatic.com/
17. World Health Organization. Integrated care for older people: guidelines on community-level interventions to manage declines in intrinsic capacity. http://apps.who.int/iris/bitstream/handle/