Malnutrition and Nursing Home Abuse and Neglect

Malnutrition occurs when a person does not get enough protein and nutrients. This causes a lack of overall energy stored in the body and leads to poor health.

Elderly people are especially prone to malnutrition. Malnutrition causes an overall decline in health, reduced strength and physical functioning, bedsores and poor wound healing, reduced mental alertness and cognition, and premature death.

Malnutrition is particularly problematic at nursing homes because nursing homes control the amount and types of foods that are available to residents.

Malnutrition does not necessarily mean that a person weighs too little. In fact, an elderly person can be obese and still be diagnosed with malnutrition.

What Causes Malnutrition at Nursing Homes?

• Understaffing: Understaffing and a lack of supervision is a main cause of malnutrition in nursing homes. Many residents require supervision, encouragement, or physical help eating. When a nursing home doesn’t have enough staff to provide this assistance, residents don’t get the assistance they need when eating.
• Depression, anxiety, or loneliness: Nursing homes are required to provide an environment that maximizes the resident’s psychological and social well-being. In reality, that is rarely the case. Depression, anxiety, and loneliness can lead to a lack of desire to eat. This in turn causes unintentional weight loss and malnutrition. Malnutrition can also cause depression. This further increases the risk of malnutrition leading to a dangerous cycle of weight loss.
• Decreased sense of taste or smell: As we age, we sometimes lose our sensitivity to taste and smell. This is a commonly overlooked condition in the elderly. Decreased taste and smell result in a poor appetite resulting in weight loss and malnutrition.
• Decreased appetite: As we age, our appetite can become reduced. This is due to a number of factors, including hormonal changes, a decreased need for energy, and changes to the digestive system.
• Medications: Certain prescription and over the counter medicines can cause malnutrition by reducing appetite. Other medications may cause nausea leading to decreased desire to eat, while some other medications may cause dry mouth, making eating unpleasant or difficult.
• Chronic illnesses: some chronic illnesses put patients at risk for malnutrition. These illnesses include cancer, congestive heart failure, chronic obstructive pulmonary disease (COPD or emphysema), diabetes, end stage renal disease, and hyperthyroidism.
• Dementia: People with dementia often are unable to communicate that they are hungry. They also sometimes are unable to realize that they are hungry because of changes in their brain. This leads to them not eating enough food to maintain their weight.
• Infections and injuries to the mouth: No one wants to eat if their mouth hurts. Anything that causes mouth pain or painful swallowing can cause malnutrition. This can be due to an infection causing a sore throat or mouth, bad teeth, or an injury.
• Difficulty swallowing: Swallowing difficulties are called dysphagia. Many patients have trouble swallowing after a brain injury or stroke or as part of the natural aging process. Patients with swallowing problems are at a high risk of becoming malnourished because they trouble eating and swallowing food.

What are the Signs of Malnutrition?

• Loss of lean muscle mass: Lean muscle mass includes not only muscle but also components of other tissues including skin, tendons, and connective tissues. Lean muscle mass plays a vital role in physical activity but also metabolism of key amino acids.
• Unintentional weight loss: Although a person can be malnourished and be overweight, many people who are malnourished suffer unintentional weight loss. Significant unintentional weight loss in the elderly is considered to be 5% of total body weight in 1 month, 7.5% of body weight in 90 days, or 10% of body weight in 180 days.
• Reduced appetite: A reduced appetite can cause malnutrition and malnutrition can further decrease a person’s appetite leading to a cycle of weight loss.
• Frequently tired or irritable: When elderly people suffer malnutrition, they lack key nutrients that are necessary to maintain energy.
• Weakness/decreased strength: Frequent weakness is a common sign of malnutrition that can be reversed with an appropriate diet.
• Frequent illness and difficulty recovery: Nutrition plays a large role in our bodies ability to fight off disease. When the body is deprived of key nutrients, it affects the immune system allowing a person to suffer from more infections and illnesses. It also makes it more difficult to get better after we are sick.
• Wounds taking a long time to heal: The skin requires nutrition to remain healthy. When a person has wounds, additional proteins and nutrients are required to heal the skin. If a person is malnourished, they will not have the reserve of energy to heal the wound resulting in wounds taking a long time to heal or not healing at all.
• Poor concentration: The brain needs a lot of energy to function properly. If the brain is deprived of nutrients, such as B vitamins and zinc, the brain has a tougher time functioning. This can result in memory issues, blanking, and difficulty concentrating.
• Feeling cold most of the time: Because there is less body fat under the skin, malnourished elderly people often feel cold or shiver.
• Swelling or fluid accumulation: Malnutrition is common in patients who have heart failure. Heart failure means that the heart is not pumping blood like it should. This causes fluid to build up in the body. Research suggests that a healthy diet improves heart failure in elderly patients.

How is Malnutrition Diagnosed?

Malnutrition is diagnosed using a clinical examination and laboratory testing. A healthcare provider, often a registered dietician, will perform a head to toe assessment looking for physical signs of malnutrition. Physical signs of malnutrition include a bony appearance. This includes the collar bones protruding or the cheeks appearing hollow. The dietician will also look for signs of dehydration, including sunken eyes. The skin may also appear a strange color and have white patches. Laboratory tests may also be needed to check the blood to look for problems with the liver or kidneys.

What are the Complications of Malnutrition?

• Increased risk of death
• Increased risk of infection
• Fatigue and lethargy
• Falls (an serious injuries from a fall)
• Heart failure
• Difficulty concentrating
• Anxiety and depression
• Wounds that don’t heal

How is Nursing Home Malnutrition Treated?

Treatment should always focus on the underlying cause of malnutrition. Nursing homes have many options they can use to treat malnutrition. Some of the treatment options include:

• Appetite stimulants: Certain medications can be used to increase an elderly person’s appetite. When properly used, these medications can prevent unintended weight loss and increase body weight to healthy levels.
• Nutritional supplements: Nutritional supplements are an easy and convenient way to increase calories and protein for nursing home residents who are at risk of losing weight. These nutritional supplements can include fortified drinks (like Ensure or protein shakes), fortified puddings, or fortified ice cream.
• Flavor enhancers: Flavor enhancers are an additive used to increase the taste of food and make it more appetizing. As we age, our sense of taste and smell can decrease. Studies have shown that adding flavor enhancers to food increases the appetite resulting in greater food consumption.
• Environment modifications: Eating is a social activity. Throughout time we have “broken bread” with our friends and family. Nursing home residents also have this natural desire to eat in a social environment. Nursing home residents, however, are often left to eat alone in their room. Or, they are forced to eat in unsanitary or undesirable surroundings. Changing the eating surroundings and improving the social environment has been shown to improve eating habits and weight gain.
• Psychosocial treatment: Weight loss is often caused by depression, anxiety, or other mental health issues. Treating those conditions can often improve weight gain. This does not simply mean adding more medication. This means improving the environment, providing enjoyable activities, and engaging residents in social events.
• Dental or mouth treatment: Oral health problems are one of the top factors leading to weight loss. Studies have shown that oral health problems are one of the leading causes of unintentional weight loss in the elderly. Nursing homes should address whether tooth or mouth problems are associated with a resident’s weight loss and provide appropriate dental or mouth treatment.
• Increased assistance: Many elderly people need increased assistance with eating. This can range from the nursing staff helping to set up the food tray for the resident, called “set up” assistance. It can also include the nursing staff providing hand-over-hand feeding, called “total assist” or “full assist.” Whatever level of support a resident needs to get adequate nutrition is what the nursing home must provide. If a resident is showing signs of weight loss, the nursing home must evaluate if the resident needs more help than is being provided.
• Medication adjustments: If medications are causing side effects of swallowing difficulties, nausea, or dry mouth, those medications may need to be adjusted. Nursing homes should consider alternative medications that do not have those unintended side effects.

Exercise and physical therapy: Physical activity can improve appetite. Walking and light exercise also improves bone strength, increases muscle mass, and supports proper immune health.

How do Nursing Homes Prevent Malnutrition?

Preventing malnutrition is in many ways similar to treating malnutrition. The main difference is the nursing home is being proactive to prevent malnutrition and not simply reacting to a person becoming malnourished.

• Nutrition assessment: The first step in nursing home care is always to perform an appropriate evaluation of a nursing home resident to find out if they are currently malnourished or at risk of becoming malnourished. The results of this assessment will determine what initial interventions are needed.
• Functional assessment: Nursing homes are required to determine how much assistance residents need when eating. This is critical because a resident will become malnourished if they are unable to feed themselves.
• Identify food tolerance and preference: As part of the assessment, nursing homes must find out what foods a resident likes and doesn’t like. The nursing home must also find out if there are any foods that they cannot tolerate. For example, if a resident is lactose intolerant, they should not be given dairy products.
• Prevent malnutrition: The goal is to prevent weight loss before it happens. This requires a team effort that involves the dietary and nursing staff. After gathering all of the information they can about the resident, the nursing home is required to create a plan to provide the resident with healthy foods that the resident will eat. They are also required to provide whatever amount of assistance the resident needs to be able to eat.
• Identify cause of weight loss: If a nursing home resident does experience weight loss, the nursing home should find out why the resident is losing weight. You cannot fix the problem unless you know the cause of the problem. The nursing home team must perform the necessary tests, physical examination, and medical investigation to learn why the resident is losing weight so they can reverse it.

Treat malnutrition and weight loss: The more weight a resident loses and the more malnourished they become, the more dangerous it is. The nursing must take whatever steps are necessary to stop the weight loss and get the resident back to a healthy weight.