BACKGROUND/STATEMENT OF PROBLEM

A. Definitions

1. Malnutrition: Malnutrition is any disorder of nutritional status, including disorders resulting from a deficiency of nutrient intake, impaired nutrient metabolism, or overnutrition.
2. Low-intake dehydration: “Low-intake dehydration is often referred to as hypertonic, hyperosmotic, or water loss, and describes an uncompensated, predominantly pure water deficit” (Beck et al., 2021, p. 3142).

B. Etiology and/or epidemiology

1. Older adults are at risk for undernutrition due to dietary, economic, psychosocial, and physiological factors (DiMaria-Ghalili & Amella, 2005).
   • Dietary intake is often reduced due to either little or no appetite (Carlsson et al., 2005; Ramic et al., 2011), problems with eating or swallowing (Serra-Prat et al., 2012), eating inadequate servings of nutrients (Ramic et al., 2011), and eating fewer than two meals a day (Ramic et al., 2011).
   • Limited income may cause restriction in the number of meals eaten per day or dietary quality of meals eaten (Samuel et al., 2012).
   • Isolation can affect intake. Older adults who live alone may lose desire to cook due to loneliness (Ramic et al., 2011; Stroebe et al., 2007), and lack of access to transportation can impact purchasing food (DiMaria- Ghalili & Amella, 2005).
   • Chronic illness can also affect intake (DiMaria-Ghalili, 2014). Disability can hinder ability to prepare or ingest food (Anyanwu et al., 2011). Depression can cause decreased appetite (Engel et al., 2011). Poor oral health (cavities, gum disease, and missing teeth) and xerostomia, or dry mouth, impair ability to lubricate, masticate, and swallow food (Palacios & Joshipura, 2015).
   • Physiological changes such as changes in taste (from medications, nutrient deficiencies, or taste bud atrophy) can also alter nutritional status (DiMaria-Ghalili & Amella, 2005).

PARAMETERS OF ASSESSMENT

A. General: During routine nursing assessment, any alterations in general assessment parameters that influence intake, absorption, or digestion of nutrients should be further assessed to determine whether the older adult is at nutritional risk. These parameters include:

1. General assessment, including present history, assessment of symptoms, past medical and surgical history, and comorbidities (DiMaria-Ghalili, 2014)
2. Social history (DiMaria-Ghalili, 2014)
3. Drug–nutrient interactions; drugs can modify the nutrient needs and metabolism of older people, and restrictive diets, malnutrition, changes in eating patterns, alcoholism, and chronic disease with long-term drug treatment are some of the risk factors in older adults that place them at risk for drug–nutrient interactions (DiMaria-Ghalili, 2014)
4. Functional limitations (DiMaria-Ghalili, 2014)
5. Psychological status (DiMaria-Ghalili, 2014)
6. Physical assessment, with emphasis on oral examination (see Chapter 26, “Oral Healthcare”); loss of subcutaneous fat, muscle wasting, and BMI (DiMaria-Ghalili, 2014); and dysphagia

B. Dietary intake: In-depth assessment of dietary intake during hospitalization may be documented with a dietary intake analysis (calorie count; DiMaria-Ghalili & Amella, 2005).

C. Risk assessment tool: The MNA should be performed to determine whether an older hospitalized patient is either at risk of malnutrition or has malnutrition. The MNA determines risk based on food intake, mobility, BMI, history of weight loss, psychological stress, or acute disease, and dementia or other psychological conditions. If the score on the MNA-SF is 11 points or less, in-depth MNA assessment should be performed (DiMaria-Ghalili & Guenter, 2008). See the “Resources” section or go to consultgerirn.org/resources for nutrition information.

D. Anthropometry:

1. Obtain an accurate weight and height through direct measurement. Do not rely on patient recall. If the patient cannot stand erect to measure height, then either a demi-span measurement or a knee-height measurement should be taken to estimate height using special knee-height calipers (DiMaria-Ghalili & Amella, 2005). Height should never be estimated or recalled due to shortening of the spine with advanced age; self-reported height may be off by as much as 2.4 cm (DiMaria-Ghalili & Amella, 2005).
2. A detailed weight history should be obtained along with current weight. Detailed weight history should include history of weight loss, whether the weight loss was intentional or unintentional, and during what period. A loss of 10 pounds over a 6-month period, whether intentional or unintentional, is a critical indicator for further assessment (DiMaria-Ghalili & Amella, 2005).
3. Calculate BMI to determine whether weight for height is within normal range: 23 to 30. A BMI below 23 is a sign of undernutrition (DiMaria-Ghalili & Nicolo, 2014).

E. Visceral proteins: Serum albumin, transferrin, and prealbumin are visceral proteins traditionally used to assess and monitor nutritional status (DiMaria-Ghalili & Amella, 2005). However, keep in mind that these proteins are negative acute-phase reactants, so during a stress state the production is usually decreased. In the older hospitalized patient, albumin levels may be a better indicator of prognosis than nutritional status (White et al., 2012). Consider using inflammatory markers (C-reactive protein or interleukin 6) to ascertain whether the changes in albumin are caused by nutritional alterations or an inflammatory state (Jensen et al., 2012; Jensen & Wheeler, 2012).

F. Functional status: Measure handgrip strength using a hand dynamometer (White et al., 2012) and review the ability to perform ADL and IADL (DiMaria-Ghalili, 2014).

G. Transitional care needs determine the ability of the patient to shop, cook, and feed self after discharge (DiMaria-Ghalili, 2014).

NURSING CARE STRATEGIES

A. Collaborate (DiMaria-Ghalili & Amella, 2005).

1. Refer to a dietitian if the patient is at risk of undernutrition or has undernutrition.
2. Consult with a pharmacist to review the patient’s medications for possible drug–nutrient interactions.
3. Consult with a multidisciplinary team specializing in nutrition.
4. Consult with a social worker, an occupational therapist, and a speech therapist as appropriate.

B. Alleviate dry mouth.

1. Avoid caffeine; alcohol and tobacco; and dry, bulk, spicy, salty, or highly acidic foods.
2. If the patient does not have dementia or swallowing difficulties, offer sugarless hard candy or chewing gum to stimulate saliva.
3. Keep lips moist with petroleum jelly.
4. Take frequent sips of water.

C. Maintain adequate nutritional and fluid intake.

1. Daily requirements for healthy older adults include 30 kcal/kg of body weight, and 1 to 1.2 g/kg of protein per day for healthy older adults. Protein may increase to 2 g/kg/d in older adults with severe malnutrition and protein losses (Volkert et al 2022). Caloric, carbohydrate, protein, and fat requirements may differ depending on the degree of malnutrition and physiological stress. The recommended daily fluid requirement is 1,600 mL/d for females and 2,000 mL/d for males unless there are clinical indicators for fluid restriction.

D. Improve oral intake.

1. Assess each patient’s ability to eat within 24 hours of admission (Jefferies et al., 2011).
2. Engage in mealtime rounds to determine how much food is consumed and whether assistance is needed (Jefferies et al., 2011).
3. Limit staff breaks to before or after patient mealtimes to ensure that adequate staff are available to help with meals (Jefferies et al., 2011).
4. Encourage family members to visit at mealtimes.
5. Ask family to bring favorite foods from home when appropriate.
6. Ask about patient food preferences and honor them.
7. Suggest small, frequent meals with adequate nutrients to help patients regain or maintain weight (Joanna Briggs Institute, 2007).
8. Provide nutritious snacks (Joanna Briggs Institute, 2007).
9. Help patient with mouth care and placement of dentures before food is served (Jefferies et al., 2011).

E. Provide conducive environment for meals.

1. Remove bedpans, urinals, and emesis basins from rooms before mealtime.
2. Administer analgesics and antiemetics on a schedule that will diminish the likelihood of pain or nausea during mealtimes.
3. Serve meals to patients in a chair if they can get out of bed and remain seated.
4. Create a more relaxed atmosphere by sitting at the patient’s eye level and making eye contact during feeding.
5. Order a late food tray or keep food warm if the patient is not in their rooms during mealtimes.
6. Do not interrupt patients for round and nonurgent procedures during mealtimes.

F. Provide specialized nutritional support (Ukleja et al., 2018; Volkert et al., 2022).

1. Start specialized nutritional support when a patient cannot, should not, or will not eat adequately and if the benefits of nutrition outweigh the associated risks.
2. Before initiation of specialized nutritional support, review the patient’s advance directives regarding the use of artificial nutrition and hydration.

G. Provide oral supplements.

1. Supplements should not replace meals but should be provided between meals and not within the hour preceding a meal and at bedtime (Joanna Briggs Institute, 2007; Wilson et al., 2002).
2. Ensure that the patient can open oral supplement packaging (Joanna Briggs Institute, 2007).
3. Monitor the intake of the prescribed supplement (Joanna Briggs Institute, 2007).
4. Promote a sip style of supplement consumption (Joanna Briggs Institute, 2007).
5. Include supplements as part of the medication protocol (Joanna Briggs Institute, 2007).

H. Follow NPO orders.

1. Schedule older adults for tests or procedures early in the day to decrease the length of time they are not allowed to eat and drink.
2. If testing late in the day is inevitable, ask the physician whether the patient can have an early breakfast.
3. See ASA practice guideline regarding recommended length of time patients should be kept NPO for elective surgical procedures.

EVALUATION/EXPECTED OUTCOMES

A. Patient will:

1. Experience improvement in indicators of nutritional and hydration status
2. Improve functional status and general well-being

B. Provider should:

1. Ensure that care includes food and fluid of adequate quantity and quality in an environment conducive to eating, with appropriate support (e.g., modified eating aids) for people who can potentially chew and swallow but are unable to feed themselves
2. Continue to reassess patients who are malnourished or dehydrated or at risk for malnutrition or dehydration
3. Monitor for refeeding syndrome

C. Institution will:

1. Ensure that all healthcare professionals who are directly involved in patient care should receive education and training on the importance of providing adequate nutrition and hydration

D. QA/QI:

1. Establish QA/QI measures surrounding nutritional and hydration management in aging patients.

E. Educational:

1. Education and training include:
   • Nutritional and hydration needs and indications for nutrition and hydration support
   • Options for nutrition support (oral, enteral, and parenteral)
   • Ethical and legal concepts
   • Potential risks and benefits
   • When and where to seek expert advice
2. Patient and/or caregiver education includes how to maintain or improve nutritional and hydration status, as well as how to administer, when appropriate, oral liquid supplements, enteral tube feeding, or parenteral nutrition.

FOLLOW-UP MONITORING

A. Monitor for gradual increase in weight over time.

1. Weigh patients weekly to monitor trends in weight.
2. Daily weights are useful for monitoring fluid status.

B. Monitor and assess for refeeding syndrome (Volkert et al 2022).

1. Carefully monitor and assess patients in the first week of aggressive nutritional repletion.
2. Assess and correct the following electrolyte abnormalities: hypophosphatemia, hypokalemia, hypomagnesemia, hyperglycemia, and hypoglycemia.
3. Assess fluid status with daily weights and strict intake and output.
4. Assess for congestive heart failure in patients with respiratory or cardiac difficulties.
5. Ensure caloric goals will be reached slowly, over more than 3 to 4 days, to avoid refeeding syndrome when repletion of nutritional status is warranted.
6. Be aware that refeeding syndrome is not only exclusive to patients started on aggressive artificial nutrition, but may also be found in older adults with chronic comorbid medical conditions and poor nutrient intake started with aggressive nutritional repletion via oral intake.

RELEVANT PRACTICE GUIDELINES

A. Preoperative fasting

1. American Society of Anesthesiologists (2017)
2. Lambert and Carey (2015)

B. Nutrition and hydration interventions

1. Ukleja et al. (2018)
2. Volkert et al. (2022)

ABBREVIATIONS

ADL           activities of daily living

ASA           American Society of Anesthesiologists

BMI            body mass index

IADL          instrumental activities of daily living

MNA-SF     Mini Nutritional Assessment-Short Form

NPO           nothing by mouth

QA/QI         quality assurance/quality improvement

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Updated: January 2025

Boltz PhD, RN, GNP-BC, FGSA, FAAN, M., Capezuti, PhD, RN, FAAN, E.A., & Fulmer PhD, RN, FAAN, T. T. (2025). Evidence-Based Geriatric Nursing Protocols for Best Practice (7th ed.). Springer Publishing. Retrieved December 17, 2024, from https://www.springerpub.com/evidence-based-geriatric-nursing-protocols-for-best-practice-9780826152763.html#tableofcontents

Chapter 12, DiMaria-Ghalili, R.A. (2025) Promotion of Optimal Nutrition in the Older Adult