Nutrition in elderly care

Nutrition plays an essential role in supporting our overall health and well-being. In order to supply all the energy and nutrients that help to keep us fit and well, we need to eat a healthy balanced diet. Eating a healthy balanced diet helps to maintain or improve body composition, cognitive health, musculoskeletal health, immune function and vascular health. This means eating a wide variety of foods in the right proportions, and consuming the right amount of food and drink to achieve and maintain a healthy body weight.

However, for some people it can be difficult to eat and drink enough nutritious food to meet the body’s needs. This can be a particular challenge for people who are unwell and / or for some older adults as they may have a poor appetite or they may lack the motivation to want to cook healthy satisfying meals regularly if it is only for themselves.

In addition, our nutritional needs do change with age, older adults generally have lower calorie needs, but similar or even increased nutrient needs compared to younger adults. In this article we will look at the importance of these nutritional needs in older people, and the things that you can do to help prevent deficiencies, we will also explain some of the consequences of not getting the correct amount of nutrients from your diet as you age.

Malnutrition

Malnutrition is a condition which happens when a person does not get the correct amount of calories and nutrients from their diet. The term malnutrition includes a deficiency or excess of energy, protein and other nutrients, and it can include both obesity and undernutrition, meaning that someone can be malnourished regardless of their size, weight or body shape. However, many of the risk factors for malnutrition that affects older people tend to lead to deficiencies of energy, protein and other nutrients, these risk factors include:

• Reduced appetite – as we age we tend to lose muscle and gain fat, which slows our metabolism down, as our metabolic rate decreases, so our appetite reduces. In addition, medication, constipation, pain and feeling ill can also affect appetite.
• Life events – these can also affect our appetite such as feeling lonely and isolated, experiencing loss or bereavement, and worrying about finances. Also low mood, tiredness and general lack of motivation such as having to cook for one can impact the enjoyment of food.
• Difficulty digesting food – a slower metabolic rate and less saliva production common in older people, can make it more difficult to chew and swallow food, as saliva is needed to moisten and digest food. Many medications can also cause a dry mouth that leads to producing less saliva.
• Long-term health conditions – these can have an impact on our ability to eat enough and can include conditions such as diabetes, hypertension, angina, chronic obstructive pulmonary disease (COPD), or chronic pain conditions, such as arthritis. Managing medical conditions through dietary restrictions can often lead to not eating enough or not consuming foods containing the required nutrients.
• Medication – Certain medications can affect a person’s ability to absorb nutrients or appetite can be affected by taking certain medications.
• Physicality – food choices can also be affected by mobility and dexterity issues, for example difficulties in using implements to prepare some foods, or inability to consume certain foods independently. In addition, as we age we may experience receding gums and / or gum disease leading to mouth sores, missing teeth and jaw pain which can reduce food choice to only easy to consume foods.
• Dementia – people living with dementia face an increased risk of malnutrition due to various factors that can impede their ability or desire to eat. The cognitive decline associated with dementia affects memory, judgment, and problem-solving skills, making it difficult for individuals to maintain proper nutrition. Research has shown that around 29% of people living with dementia in the UK experience malnutrition.
• Reduced sense of taste and smell – with age the number of taste buds that we have decreases, so it becomes harder to distinguish between different tastes such as sweet, salty, sour and bitter, this can change the pleasure that we get from food and drink, and can affect our food preferences.
• Changing nutritional needs – as we age our dietary needs change, such as eating low-fat products or having less sugar or treats that were part of a diet focussed on weight control may actually contribute to malnutrition in an older person where weight loss is not a health benefit.

The National Institute for Health and Care Excellence (NICE) defines a person as being malnourished if they have:

• A body mass index (BMI) of less than 18.5 kg/m2
• Unintentional weight loss greater than 10% within the past 3 – 6 months
• A BMI of less than 20 kg/m2 and unintentional weight loss greater than 5% within the past 3 – 6 months

Malnutrition can affect anyone, but it is more common for older adults and those who are living on their own. According to the British Geriatrics Society, it is estimated that around one in ten people over the age of 65 are malnourished, or are at risk of malnutrition that is about 1.3 million older people in the UK today. 

The BAPEN malnutrition and nutritional care survey, undertaken in October 2022 in conjunction with the UK Malnutrition Awareness Week reported that:

• One-third (32%) of people in the UK aged 65 years or over are at risk of malnutrition on admission to hospital
• 50% of people admitted to hospital from care homes were at risk of malnutrition
• In hospitals, 44% of patients were at risk of malnutrition

Malnutrition affects every system in the body and results in increased vulnerability to illness and complications, which can lead to prolonged hospital stays, more visits to the doctor and, in some cases, even death. BAPEN also reported that malnourished people:

• Saw their GP twice as often
• Had 3 times the number of hospital admissions
• Stayed in a hospital more than 3 days longer than those who were well-nourished
• Have more ill health (co-morbidities)

Malnutrition can be difficult to spot, and are sometimes are not obvious until malnutrition is advanced. Whilst the main symptom of malnutrition is unintentional weight loss, it is possible to be a healthy weight or even overweight and still be malnourished. Some of the signs and symptoms of malnutrition can include:

• Reduced appetite
• Lack of interest in food and drink
• Lethargy or feeling tired all the time
• Feeling weaker
• Loss of muscle size and strength
• Feeling cold most of the time
• Getting ill often and taking a long time to recover
• Mood changes such as low mood, sadness and depression
• Poor concentration
• Wounds taking a long time to heal

It is important to recognise that unintentionally losing weight and losing the desire to eat when older is not a normal sign of ageing. It is also important to remember that these signs and symptoms rarely occur in isolation, for example, having a small appetite may lead to having lower energy, making shopping and / or cooking even harder, which may lead to making less healthy choices, thereby creating a downward spiral.

Diet and illness links

The connection between the food that we eat and our body’s health and wellbeing are inseparable. Eating an unhealthy diet can have serious consequences and can increase someone’s risk for developing different health conditions and diseases. For example, a diet lacking sufficient Vitamin D is linked to osteoporosis and a higher risk of falls, and diets high in sugar can harm gut bacteria and promote insulin resistance, chronic inflammation, and overall disease risk.

Unhealthy diets and the resulting malnutrition are major causes of many non-communicable diseases (NCDs) such as type 2 diabetes, cardiovascular disease, stroke, dysphagia (swallowing problems) and some cancers including oesophageal cancer, tracheal, bronchus and lung cancer, colon and rectum cancer. In the UK, unhealthy diets are estimated to cause more than 75,000 premature deaths each year.

Ultra-processed food (UPF) is directly linked to 32 harmful effects to health, including a higher risk of heart disease, cancer, type 2 diabetes, adverse mental health and early death, according to the world’s largest review of its kind published in the British Medical Journal (BMJ). They found that more than half the average diet in the UK now consists of ultra-processed food, such as cereals, protein bars, fizzy drinks, ready meals and fast food, these products tend to be high in added sugar, fat, and / or salt, but are low in vitamins and fibre, they also undergo multiple industrial processes and often contain colours, emulsifiers, flavours and other additives.

The review concluded that “Overall, direct associations were found between exposure to ultra-processed foods and 32 health parameters spanning mortality, cancer, and mental, respiratory, cardiovascular, gastrointestinal, and metabolic health outcomes.”

Dietary choices significantly affect health, influencing disease risk, however research shows that good dietary habits can offer some therapeutic and protective qualities as many nutrients in food promote health and protect the body from disease. For example, the Mediterranean diet, which is rich in healthy fats, whole grains, and vegetables, is linked to a reduced risk of heart disease, diabetes, certain cancers, obesity and neurodegenerative conditions such as Alzheimer’s disease and other memory disorders.

Getting the right nutrition can improve health and wellbeing, especially in older people who become more susceptible to illness and lethargy. A lack of adequate nutrition can lead to weight loss and muscle wasting, making individuals frailer and more susceptible to falls, fractures, and infections. It also weakens the immune system, increasing the risk of infections, this is particularly concerning for people with dementia, who may already have compromised health due to other underlying conditions. A constant supply of nutrients, including vitamins, minerals, and fats are also required to enable the brain to function optimally, when deprived of these nutrients, cognitive decline can accelerate, worsening symptoms such as confusion, memory loss, and mood disturbances.

Good nutrition provided by a balanced diet is vital for supporting the overall wellbeing, vitality and independence of older adults. Without proper nutrition, their bodies cannot stay healthy, fight off disease, or deal with illnesses that they may already have.

Nutritional needs for the elderly

A varied diet that includes plenty of nutrient-dense foods is recommended for everyone, regardless of age. A body needs carbohydrates for energy, proteins to grow and repair, and healthy fats to protect organs and support the brain. However, as we age, our nutritional requirements change, creating a set of unique needs in our later years. Many people eat less as they get older and this can make it harder to make sure that their diet has enough variety to include all the nutrition that they need.

Energy requirements decrease in older adults as they are generally less physically active than they were when they were younger, however, there is a difference between energy requirements and nutrient requirements, and nutrient requirements actually remain the same, if not increase, as we get older.

Studies suggest that an individual over 65 years of age may need twice as much protein as a teenager to maintain their muscle mass and for the repair and maintenance of body cells and tissues. Older people are at greater risk of muscle wasting and loss of lean body mass, so the requirement to repair becomes more acute, putting greater emphasis on obtaining the correct quantity of protein. Muscle mass loss reduces independence whilst increasing the risk of falls and mortality. Good sources of protein can be found in foods such as meat, fish, eggs, or dairy, so older people’s diets should include a source of protein in every meal to ensure that they are getting a sufficient supply.

Fibre is an important component of everyone’s diet as it promotes a healthy gut and prevents constipation. For older adults in particular consuming sufficient fibre is vital to reduce the risk of bowel related disorders such as cancer.

Bone density decreases with age, particularly in women. Calcium is essential to maintaining bone health and to reduce the risk of osteoporosis. Foods including milk, yoghurt, cheese and leafy green vegetables can provide calcium and should be included in an older person’s diet to help to support bone health. Vitamin D aids the absorption of calcium into bones and can be provided by the action of sunlight on the skin, however older adults who may be more housebound and less exposed to sunlight may benefit from also eating Vitamin D enriched mushrooms and oily fish such as trout and salmon and / or taking additional Vitamin D supplements.

Vitamin B12 commonly called folate, is a key nutrient used for energy production, and deficiency of Vitamin B12 can cause anaemia which causes the body to produce abnormally large red blood cells that cannot function properly. Red blood cells carry oxygen around the body using a substance called haemoglobin. Anaemia is the general term for having either fewer red blood cells than normal or having an abnormally low amount of haemoglobin in each red blood cell. Vitamin B12 is found in egg yolks, calves’ liver, meat, fish and shellfish, however Vitamin B12 becomes harder to obtain from food by older adults as a consequence of falling stomach acid levels, so Vitamin B12 supplements can help.

Iron is a key component of haemoglobin, which enables oxygen to be transported around the body. An Iron deficiency could result in a person becoming lethargic, or in extreme cases, anaemic. Iron can be ingested from meat, leafy green vegetables, dried fruit, and / or given as a supplement.

Vitamin C is crucial for the creation of body tissues, aids in the healing process and is an antioxidant that may play a role in the prevention of heart disease and cancer. It is also needed to help absorb Iron, which is particularly important as older adults are less effective at Iron absorption. Fresh fruit and vegetables can help to optimise vitamin C levels, but some supplementation may be required for older adults.

Zinc helps the body’s immune system and metabolism to function, and is also important for wound healing and for the sense of taste and smell. Zinc may also significantly reduce the risk of age-related diseases, such as pneumonia, infection, and age-related macular degeneration (AMD), a common condition that affects the middle part of a person’s vision. Many animal and plant foods are naturally rich in Zinc, making it easy for most people to consume adequate amounts.

It is essential that older adults drink plenty of water as it is essential to keep hydrated, to maintain concentration levels and to prevent constipation. The human body holds onto less water as we age, putting greater emphasis on drinking more.

Older adults are at greater risk of developing cardiovascular disease (CVD) and high blood pressure so whilst foods containing sodium and saturated fats should be avoided, those containing Omega 3 and Omega 6 polyunsaturated fatty acids should be increased to help provide energy for the body and to help manage inflammation that occurs with some chronic diseases. Omega 3 and Omega 6 can be found in oily fish, nuts and seeds.

Healthy diets in elderly care

Older adults require a more protein-dense, nutrient-rich diet to help maintain their health and wellbeing and to ward off the effects of malnutrition. However, three large meals a day can be overwhelming for older adults whose appetites may have diminished, so smaller meals supplemented by nutritious snacks may be a more effective option.

As we have seen, adequate nutrition and hydration are essential for the body’s overall functioning and for the maintenance and repair of cells and organs. Having a balanced, healthy diet that includes items from the main food groups that is carbohydrates, proteins, fruit and vegetables and dairy, ensures the intake of the nutrients, vitamins and minerals that an older adult needs.

The Government’s Eatwell Guide shows the proportions in which different types of foods are needed to have a well-balanced and healthy diet. In the case of poor appetite, meals can be supplemented with protein-rich fortifiers and nutritional drinks. To increase the intake of vital nutrients such as vitamins, iron and calcium and to increase calorie intake, the NHS recommends adding butter, cream, full-fat milk or cheese to snacks or meals.

High protein meal ideas might include:

• 2 poached eggs on wholemeal toast
• Cereal with milk
• Baked beans on wholemeal toast
• Mixed vegetable omelette
• Chicken and vegetable noodle stir fry
• Chicken and pasta bake
• Salmon risotto
• Salmon and vegetable tray bake

Snack suggestions high in protein might include:

• Hummus with vegetable sticks
• Yogurt with chopped fruit
• Crackers and cheese
• Hard-boiled eggs
• Peanut butter with apple slices
• Peanut butter on wholemeal toast
• Smoothies

Healthy snacking can be a great way to encourage an older adult who has a diminished appetite to graze throughout the day and maintain their nutritional requirements.

Encouraging healthy choices

It can often be hard for older adults to eat enough food throughout the day to sustain them and to provide their bodies with the important nutrition needed, as loss of appetite in older adulthood is not uncommon. This is why it is important to not try to eat too much in one go. Aim to have at least three small meals each day with two or three snacks or milky drinks in between. Small portions are often more appealing and can always be followed by a second helping.

Adding variety to the diet and including favourite foods can help to make food more enticing. A balanced diet for older adults should include:

• At least 8-10 glasses of fluid each day, this includes fruit juice, milky drinks, tea, coffee and water
• At least one portion of fruit each day and / or a glass of fresh fruit juice or fruit cordial rich in vitamin C
• Protein foods in at least two meals each day such as meat, poultry, fish, beans, pulses, dahl, dairy foods, and eggs
• An energy food at each meal, such as bread, potato, rice, pasta or cereals
• Some foods that are rich in calcium and Vitamin D for healthy bones. Calcium is found in milk, cheese, eggs and yogurt and Vitamin D from for example sardines, margarine and fortified breakfast cereals

Adding as many different colours and flavours to a meal through a variety of vegetables and / or by adding sauces, herbs, spices etc. will not only increase its nutritional profile, but will also make for a more enjoyable eating experience. Taking pleasure in food and drink can help an older adult to eat well and maintain their health and wellbeing. For some, sharing a meal with friends or family helps or for others eating alone is more beneficial, whichever suits, appetising and nutritious food is key to eating well and making a difference to immediate and long term health.