ARTICLE IN PRESS

International Journal of Nursing Studies 41 (2004) 225–237

Contents

1. Intr

2. Asso

2.1.

2.2.

2.3.

3. Prev

3.1.

3.2.

4. Edu

4.1.

*Correspondi

E-mail addre

0020-7489/$ - see

doi:10.1016/S002

Review

Nutritional status of older people in long term care settings:current status and future directions

David T. Cowana,*, Julia D. Robertsb, Joanne M. Fitzpatrickb,Alison E. Whilec, Julie Baldwind

aResearch Fellow, Ageing and Health Section, Florence Nightingale School of Nursing and Midwifery, King’s College London,

James Clerk Maxwell Building, 57 Waterloo Road, London SE1 8WA, UKbSenior Lecturer, Ageing and Health Section, Florence Nightingale School of Nursing and Midwifery, King’s College London, UKcProfessor of Community Nursing, Head of Primary and Intermediate Care Section, Florence Nightingale School of Nursing

and Midwifery, King’s College London, UKdResearch Associate, Ageing and Health Section, Florence Nightingale School of Nursing and Midwifery, King’s College London, UK

Received 20 March 2003; received in revised form 1 July 2003; accepted 14 July 2003

Abstract

Despite being preventable and treatable, in the 21st Century, malnutrition remains a problem in the developed world

and the nutritional needs of many older people in long-term care settings are not met. The UK government has pledged

to provide high-quality care for this sector of the population, including minimum standards to ensure adequate

nutrition. However, research is still needed into the detection, prevalence, cause and effects of malnutrition and

maintenance of optimum nutrition; and to address the lack of training and education among those caring for older

peoples. In the interim, simple measures such as monitoring older people’s weight regularly need to be implemented as a

surveillance measure of nutritional status.

r 2003 Elsevier Ltd. All rights reserved.

Keywords: Nutritional status; Malnutrition; Older people; Care homes

oduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226

ciated causes and effects of malnutrition among older people . . . . . . . . . . . . . . . 227

Associated causes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227

Associated effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228

Cause and effect relationship . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229

alence and implications of malnutrition among older people . . . . . . . . . . . . . . . . 230

Prevalence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230

Detection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231

cation and training needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232

Remedies for malnutrition and maintenance of nutritional status . . . . . . . . . . . . . 233

ng author. Tel.: +44-20-7848-3215.

ss: david.t.cowan@kcl.ac.uk (D.T. Cowan).

front matter r 2003 Elsevier Ltd. All rights reserved.

0-7489(03)00131-7

ARTICLE IN PRESS

5. Interim measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233

6. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234

7. Uncited reference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235

D.T. Cowan et al. / International Journal of Nursing Studies 41 (2004) 225–237226

1. Introduction

Adequate nutrition is described by the World Health

Organisation (WHO) as a cornerstone of the health of

all people and a fundamental human right (WHO,

2002). While Garrow (1994) noted that 18th Century

nutritional science had been rudimentary, by the mid-

19th Century, nutrition was recognised as an important

yet neglected area of patient care (Holmes, 1996; Perry,

1997). Despite claims that in the period between the

mid-19th and mid-20th Centuries improved nutrition

was an important factor in the decline of mortality rates

in the developed world (McKeown, 1976; Illich, 1995),

by the end of the 20th Century, the neglect of nutrition

in clinical medicine was apparent (King’s Fund Centre,

1992; McWhirter and Pennington, 1994; BAPEN, 2002;

Campbell et al., 2002; RCP, 2002). Reflecting this,

significant levels of malnutrition have been found

among hospitalised patients (Garrow, 1994; McWhirter

and Pennington, 1994; Eberhardie, 2002). Furthermore,

malnutrition is particularly prevalent among older

people (Lehmann, 1989; McWhirter and Pennington,

1994; Devlin, 2000; Greene-Burger et al., 2001) and

especially among older people resident in long-term care

facilities (Morely and Silver 1995; Elmstahl et al., 1997;

Crogan and Shultz, 2000; Kayser-Jones, 2000; Neel,

2001; Howell, 2002). Recent estimates for the United

Kingdom (UK) indicate that approximately 157,500

older people live in nursing homes and 288,750 older

people live in residential homes (Royal Commission on

Long Term Care, 1999). These figures suggest that

significant numbers of older people in the UK may be at

risk of malnutrition.

In response to the transition to an older population

profile over the last century (Gariballa and Sinclair,

1998; Pickering et al., 2001) the European Union has

identified the provision of health and social care for this

population as a crucial challenge for the 21st Century. In

addition to merely extending life, ways of reducing

morbidity and coping with disability, preventing in-

capacity, extending the quality of life and enhancing the

functional independence of older people are considered

to be an important component of service provision

(European Commission Research Directorate, 2002). In

Britain, the number of people aged over 65 years has

doubled in the last 70 years and the number of people

over 90 years is expected to double in the next 25 years,

which will increase the need for healthcare (DoH, 2001).

The UK government has pledged to provide high-

quality care and treatment, regardless of age, to treat

older people with respect and dignity and to allocate fair

resources for conditions that affect them, while simulta-

neously attempting to reduce the financial burden of

long-term care (DoH, 2001). National minimum stan-

dards for care homes for older people aim to ensure that

the health needs of residents include a full assessment of

the nutritional status and monitoring of their nutritional

status continues throughout their stay (DoH, 2002).

However, if these aims are to be realised, it is clear that

continuing problems of unrecognised and untreated

malnutrition and sub-optimal nutrition among older

people need to be addressed (MAG, 2000). This paper

discusses these issues and suggests ways for improving

the current situation.

A review of the literature was undertaken using

electronic databases, journals, books, abstracts, con-

ference proceedings, reports, relevant organisations,

reference lists from any of the above, and any other

form of relevant literature that was encountered.

CINHAL, Medline, Nutrition Abstracts and Reviews:

Human and Experimental, The British Nursing Index

and Ageline were all searched for English language

articles, entering the following terms: nutrition; under-

nutrition; malnutrition; older people; elderly people;

care homes; and nursing homes. MeSH headings

searched were: under-nutrition, malnutrition, homes

for the aged and ageing. Initially, with a view to

obtaining information with contemporary relevance,

electronic searches were extended back to 1995. How-

ever, manual searches of articles and reference lists

produced older articles which still have relevance. For

the purposes of this paper, the term ‘care home for older

people’ may be defined as either a residential home, a

nursing home or a home with dual status providing

residence and/or nursing.

The publications reviewed included empirical reports,

reviews, commentaries, editorials, chapters in books,

reports from professional bodies and associations,

letters and newsletters. Themes addressed included: the

growing world population of older people, the perceived

ARTICLE IN PRESSD.T. Cowan et al. / International Journal of Nursing Studies 41 (2004) 225–237 227

prevalence of malnutrition or sub-optimal nutrition

among older people in care facilities within the devel-

oped world and the causes and effects of malnutrition.

In addition, there were reports of perceived inappropri-

ate attitudes among health care professionals involved in

the care and treatment of older people and a lack of

nutritional knowledge among these staff, combined with

a need to inform older people themselves how they may

benefit from improved nutritional knowledge. Also

highlighted was the need for the development and

evaluation of effective malnutrition screening and

assessment tools, the development of remedies for

malnutrition and the development and implementation

of regimes for the maintenance of optimum nutrition.

The review is structured around four key headings,

namely: the associated causes and effects of malnutrition

among older people; the prevalence and implications of

malnutrition among older people; the education and

training needs of healthcare professionals; and measures

that may be undertaken in the interim. With regard to

each of these headings, it is also suggested where

research is needed in order to improve the nutritional

status of older people in long-term care settings.

Table 1

Individual causes of malnutrition among older people

Ageism Abuse

Impaired speech Institutionalisation

Impaired vision Apathy

Impaired hearing Lack of exercise

Dementia General attitude

Confusion Alcohol intake

Poor communication Arthritis

Depression Cancer

Sensory loss (taste and/or smell) Diabetes

Inability to chew and swallow Tremors

Poor posture and mobility Dehydration

Poor manual dexterity Drug therapy

Locus of control

(being dependent on others)

Decline in oral

health

Belief system Pain

Isolation Bereavement

2. Associated causes and effects of malnutrition among

older people

For at least a decade, much has been written about

malnutrition and the perceived causes of such among

older people who are resident in care homes (Nazarko,

1993, Morely and Silver, 1995; Elmstahl et al., 1997;

Kamel et al., 1998; Copeman, 2000; Neel, 2001; Eberhardie,

2002; Howell, 2002). Equally, the effects of malnutrition

are well documented in the literature (Booth, 1993;

Mion et al., 1994; Dormenval et al., 1998; Mojon et al.,

1999; Noble, 1999; Fitzpatrick, 2000; Kayser-Jones,

2000; Sheiham and Steele, 2001; Neel, 2001).

2.1. Associated causes

The perceived causes of malnutrition are numerous

and may be divided into two main categories: individual

and organisational (Read and Worsfold, 1998; Copeman,

2000). The individual factors can be sub-divided into

physical causes (Booth, 1993; Mion et al., 1994;

Davidhizar and Dunn, 1996; Noble, 1999; Copeman,

2000) or causes due to the particular social environment

of a given individual (Kvale and Horvath, 1989;

Kerstetter et al., 1992; Dwyer, 1993; Noble, 1999;

Copeman, 2000). There may, however, be a certain

amount of overlap between categories both within and

across these divisions, because individual causes may be

difficult to distinguish from physical, individual environ-

mental or organisational environmental causes. For

example, in the case of an older person receiving drug

therapy, this could be seen as resulting from the

individual’s particular environment, the effects of the

drug may have physical manifestations such as anorexia

or mal-absorption of nutrients and the drug therapy may

also be the consequence of an inappropriate drug

prescribing regime within an organisation.

The perceived physical causes of malnutrition among

older people are often partly attributed to body changes

and disorders that occur as a result of increasing age

(Davidhizar and Dunn, 1996; Chan, 1999; Copeman,

1999). These affect the alimentary system, the haemo-

dynamic system (heart and circulation), the endocrine

system, the renal system, the immune system, the central

nervous system and the senses (Mion et al., 1994; Chan,

1999; Howell, 2000; Copeman, 2000). Individual factors

associated with these changes, that may lead to

malnutrition are: impaired speech, impaired vision and

hearing, dementia, confusion, resultant poor commu-

nication, depression, sensory loss (taste and/or smell)

(Davidhizar and Dunn, 1996; Copeman, 2000), poor

posture and mobility, poor manual dexterity, pain,

apathy (Copeman, 2000); dehydration; and dysphagia

(Davidhizar and Dunn, 1996; Kayser-Jones, 2000).

Furthermore, the importance of good oral health in

maintaining adequate nutritional intake among older

people has been emphasised (Dormenval et al., 1998;

Mojon et al., 1999; Fitzpatrick, 2000; Sheiham and

Steele, 2001). Common problems in this area include the

absence of teeth, poor oral hygiene, oral mucosal

atrophy, gum infections, dental caries and poorly fitting

dentures (Walls, 1999; Sheiham and Steele, 2001).

Specific illnesses that are prevalent among older people

may also cause malnutrition (Davidhizar and Dunn,

1996) and these include arthritis (Nazarko, 1993),

cancer, diabetes, Parkinson’s disease, Alzheimer’s dis-

ease and depression (Booth, 1993; Davidhizar and

Dunn, 1996; Kamel et al., 1998; Neel, 2001) (Table 1).

ARTICLE IN PRESS

Table 2

Organisational factors causing malnutrition

Failure to help patients to eat Leaving residents in bed all day

Failure to recognise malnutrition Inadequate training and education of staff

Lack of screening Monotonous unappetising diet

Importance of nutrition not realised, Treatment too late Soft diet regime (as opposed to ensuring dentures fit)

Absence of dietition Inappropriate drug prescribing

Lack of staff Insufficient data collection

Lack of communication between staff Lack of enforcement of regulations

D.T. Cowan et al. / International Journal of Nursing Studies 41 (2004) 225–237228

Individual environmental effects may be due to lack

of communication (Copeman, 2000), anxiety, excessive

intake of alcohol (Goodwin, 1989; Booth, 1993; Dwyer,

1993; Mion et al., 1994), an individual’s general attitude

(Neel, 2001) their locus of control (Kerstetter et al.,

1992), dependence on others (Nazarko, 1993), ageism

(Peachey, 1999), belief system, isolation, bereavement,

abuse, institutionalisation (Goodwin, 1989; Kerstetter

et al., 1992; Dwyer, 1993) lack of or reduction in exercise

and physical activity (WHO/Tufts, 2002) and drug

therapy (Varma, 1994; Neel, 2001) (Table 1).

Subsequent to a review conducted as part of a

study undertaken by The WHO and Tufts University

(2002), it was concluded that strength training for

older people helped to stop or reverse the age-associated

loss of body protein and increased bone density.

Furthermore, increasing muscle strength and muscle

mass in older people was a useful strategy for maintain-

ing functional status and independence (WHO/Tufts,

2002).

Older people often require drug therapy such as anti-

depressants, dopamine antagonists, diuretics, hyperten-

sive agents, opioids and non-steroidal anti-inflammatory

drugs (NSAIDs) (Neel, 2001). These medicines in turn

may induce anorexia leading to sub-optimal nutrition or

malnutrition (Nazarko, 1993; Varma, 1994; Davidhizar

and Dunn, 1996; Holmes, 1996; Neel 2001). Further-

more, in the absence of adequate nutrition enabling

adequate metabolism, distribution and excretion of

drugs, effective drug therapy will not occur (Neel,

2001). Conversely, drugs have the potential to affect

the ingestion, absorption, distribution and elimination

of nutrients (Kvale and Horvath, 1989; Mion et al.,

1994). In the United States of America (USA), Varma

(1994) undertook a study of medical records of older

people ðn ¼ 390Þ living in care homes ðn ¼ 10Þ toidentify the risks of drug induced weight-loss and

specific nutrient deficiencies. Varma (1994) found that

over half of the sample of older people were receiving

drugs that are known to induce deficiencies of vitamins

B-12, B-6, C, D, K, folate, phosphate, potassium,

calcium, magnesium and zinc but that testing for

deficiencies was inadequate and very few of these older

people appeared to receive adequate vitamin or mineral

supplementation.

Regarding organisational factors associated with

malnutrition in UK care homes, Copeman (2000) has

suggested that poor management structures combined

with inadequate staff training and education increase the

risk of care home residents becoming malnourished.

Also, how meals are served and presented and the

environment where this takes place are important

organisational factors in maintaining adequate nutrition

among residents (Copeman, 2000). Read and Worsfold

(1998) and Copeman (2000) have advised that eating

areas need to be free from noise, offensive odours and

other distractions, with sufficient time allowed for

consumption, appropriate assistance (discreet if neces-

sary), with appropriate cutlery, furniture and seating

arrangements.

Crogan et al. (2001) survey of nurses ðn ¼ 44Þ andnursing assistants (support workers) ðn ¼ 99Þ in USAcare homes ðn ¼ 5Þ for older people, found that shortageof time, understaffing, overcrowding of residents, com-

munication problems between staff, quality and quantity

of food and the need for further training of nurses and

nursing assistants were organisational factors affecting

the nutritional status of care home residents. Other

factors noted in the literature were absence of a dietitian

(Nazarko, 1993; Lauque et al., 2000), inadequate

screening (Gariballa and Sinclair, 1998; Holmes, 2000;

Lauque et al., 2000; Campbell et al., 2002; Jones, 2002),

failure to realise the importance of nutrition, failure to

recognise malnutrition (Gariballa and Sinclair, 1998;

Copeman, 2000; Kayser-Jones, 2000), ageism (Peachey,

1999), treating malnutrition too late, leaving residents in

bed all day (Lauque et al., 2000), a soft diet regime (as

opposed to ensuring that dentures fit) (Nazarko, 1993;

Davidhizar and Dunn, 1996), and inappropriate pre-

scribing of drugs (Dwyer, 1993; Varma, 1994; Neel,

2001). Organisational factors identified by Greene-

Burger et al. (2001) ranged from inadequate staffing to

lack of enforcement of regulations (Table 2).

2.2. Associated effects

The numerous effects of malnutrition are well

documented in the literature. These include loss of

strength, decreased energy levels, reduction in body

tissue mass, adverse psychological changes such as

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Table 3

Effects of malnutrition in older people

Increased mortality Complication of illness

Loss of strength Reduced muscle function

Lowered body tissue mass Increased risk of hypothermia

Depression Delayed wound healing

Lethargy Increased mortality

Anxiety Increased risk of

thromboembolism

Respiratory impairment Osteoporosis

Decreased oxygen

consumption

Increased risk of fracture

Increased chance of

re-admission to hospital

Decreased cardiac function

Fatigue Increased risk of infections

Oedema Delayed recovery from illness

Pressure ulcers Prolonged hospitalisation

Anaemia Decreased energy

Immune dysfunction

D.T. Cowan et al. / International Journal of Nursing Studies 41 (2004) 225–237 229

depression (Morely and Kraenzle, 1994; Copeman,

1999) and dementia (Andrieu et al., 2001). A vicious

cycle may develop, of apathy, anorexia (Perry, 1997),

decreased mobility, pressure sore formation, (Copeman,

1999), osteoporosis (Eberhardie, 2002), oxygen deficit

and decreased cardiac function (Copeman, 1999).

Impaired immunity (Chandra, 1990), may lead to

increased risk of infectious disease (1990, Kerstetter

et al., 1992; Copeman, 1999). Complication of and

delayed recovery from illness (Copeman, 1999; Lauque

et al., 2000) may lead to prolonged hospitalisation

(Pettigrew and Hill, 1986) and increased chance of re-

admission to hospital (Sullivan, 1995) (Table 3).

While these adverse effects are applicable to all age

groups, they are especially hazardous for older people,

particularly those who reside in care homes, who often

exhibit high levels of frailty and disability (Elmstahl

et al., 1997; Todorovic, 2000). Furthermore, the many-

fold effects of malnutrition may exacerbate each other,

particularly in frail older people. For example, having an

infection may result in reduced appetite, reduced

absorption and internal diversion of nutrients, leading

to a vicious cycle of infection and malnutrition

(Kerstetter et al., 1992). Depression (Morely and

Kraenzle, 1994; Copeman, 1999), dementia and confu-

sion (Mion et al., 1994; Andrieu et al., 2001) are

associated with the causes of malnutrition but they are

also the effects, and are likely to worsen as malnutrition

progresses, again leading to a potentially vicious cycle of

symptoms (Todorovic, 2000). Poor mobility combined

with muscle weakness and osteoporosis may lead to falls

and other trauma resulting in fractured bones, pain, the

need for analgesics, further incapacity, depression and

further tissue wasting. Pain, depression and the admin-

istration of NSAIDs and opioids may then result in

further decreased nutritional intake (Neel, 2001).

In addition to the associated direct physical effects of

malnutrition for older people, evidence suggests not

surprisingly, that these effects, particularly delayed

recovery from illness and prolonged hospitalisation,

incur a financial cost (King’s Fund Centre, 1992). The

King’s Fund report highlighted evidence demonstrating

reduced complication rates and decreased hospitalisa-

tion times resulting from improved nutrition (King’s

Fund Centre, 1992). In a review of studies focussing on

malnutrition and poor patient outcomes, Tucker and

Miguel (1996) found that early and appropriate nutri-

tional intervention in at risk patients clearly improved

health outcomes and reduced costs. Tucker and Miguel

(1996) concluded that the findings demonstrated that

there was a significant gap in institutions in the USA,

between what was being saved through nutritional

intervention and what could be saved if nutrition care

practices were improved. In view of these reports it is

likely that there is the potential for financial savings, for

example through reduction of intensity and length of

illness, resulting from improved nutritional intervention

in UK care homes for older people. Research is, there-

fore, needed to assess the cost-effectiveness of nutritional

interventions.

2.3. Cause and effect relationship

Goodwin (1989) and Dwyer (1993) have highlighted

the importance during the nutritional assessment of

older people, of establishing an accurate cause or effect

relationship. Clearly, there is a need to establish whether

older people are at risk of malnutrition due to disease,

disability and/or drugs or whether they may be at risk of

disease and/or disability due to their nutritional status

(Dwyer, 1993). There have been numerous associations

made between poor nutritional status and ill health

(Sullivan, 1995; Morely and Kraenzle 1994; Holmes,

1996; Perry, 1997; Copeman, 2000; Andrieu et al., 2001).

In discussing associations between the nutritional status

and the health status of a given population, Goodwin

(1989) used the example of depressed cognitive function

being associated with sub-clinical deficiencies of certain

vitamins. Goodwin (1989) argued that given this

association, it is possible that sub-clinical deficiencies

cause depressed cognitive function, or that depressed

cognitive function causes sub-clinical deficiencies, or,

some other undetermined factor or factors are respon-

sible for both depressed cognitive function and sub-

clinical deficiencies. Goodwin (1989) and more recently

Sayhoun (2002) have recommended controlled, pros-

pective studies to effectively separate cause and effect

and to assess the cognitive effects of nutritional

supplementation.

In a longitudinal study of older Japanese men ðn ¼3734Þ living in the USA, Masaki et al. (2000) found thatcombined vitamin E and C supplementation was

ARTICLE IN PRESSD.T. Cowan et al. / International Journal of Nursing Studies 41 (2004) 225–237230

associated with an 88% reduction in the frequency of

vascular dementia. They concluded that further studies

to assess the protective antioxident effects of vitamins E

and C for both vascular dementia and Alzheimer’s

disease would be timely (Masaki et al., 2000). Clearly,

further studies of this nature, as well as similar studies to

assess the effects of nutritional supplementation on

many of the other nutrition-associated adverse health

effects highlighted in this paper, need to be conducted

without delay. However, in this era of high-technology

investigation, the very simplicity of such studies may

have already retarded and continue to retard their

implementation (Goodwin, 1989).

3. Prevalence and implications of malnutrition among

older people

Morely et al. (1995) have highlighted that malnutri-

tion is common among nursing home residents and that

protein energy under-nutrition is endemic in this setting

with a prevalence ranging from 17% to 65%. Neel

(2001) suggested that approximately half of the residents

in care homes in the USA are undernourished and

Crogan et al. (2001) claimed that in some homes the rate

is as high as 85%. In the UK there has been a lack of

research regarding the prevalence of malnutrition

among older people in long-term care (MAG, 2000).

The recent Health Survey for England (HSE) commis-

sioned by the Department of Health, of the general

health of older people and their use of health services,

did not, however, directly assess for the incidence of

malnutrition (HSE, 2000).

The UK National Diet and Nutrition Survey of

people aged 65 years and older, undertaken among older

people ðn ¼ 453Þ residing in a sample of care homes ðn ¼155Þ; found that 15% of women and 16% of men

resident in care homes were malnourished (Finch et al.,

1998) compared to 6% of women and 3% of men who

were living independently in the community. In a survey

of case notes ðn ¼ 600Þ selected from healthcare

directorates ðn ¼ 20Þ in Scotland, Campbell et al.

(2002) found that contrary to earlier recommendations

from the King’s Fund (1992) and the British Association

of Parenteral and Enteral Nutrition (BAPEN, 2002)

only 41% of hospital patients had both their weight and

height recorded.

3.1. Prevalence

There have been some recent estimates of the

prevalence of malnutrition among older people resident

in care homes in the USA (Crogan et al., 2001; Neel,

2001) and Finch et al. (1998) have also provided limited

UK data. However, despite comments made a decade

ago, that little was known about the problem among

older people in this setting in the UK (Nazarko, 1993),

relatively little is known still (MAG, 2000). Improved

methods of assessment of nutritional status are required

to enable prevalence estimates of this problem can be

better facilitated. In the interim, pilot studies to explore

the extent of the problem, using simple methods such as

weight loss over time, could be undertaken with relative

ease.

Over 10 years ago the King’s Fund’s (1992) report

indicated that routine monitoring of nutritional status

could ensure that potential problems are identified and

acted upon before they cause ill health. At the same time

it was suggested that in addition to pulse, respiratory

rate and temperature, nutritional status should be

considered as a vital sign when caring for older people

(Kloster Yen, 1992). Kloster Yen (1992) highlighted that

recording older people’s weight and height for a body

mass index (BMI) calculation was relatively easy.

Shortly afterwards the UK Royal College of Nursing

(RCN) formulated a national set of guidelines for

‘Nutrition in the Older Adult’ (RCN, 1993). This was

in response to a perceived lack of emphasis on the

nutritional care afforded to the increasing proportion of

older people and failure to recognise contributing

factors to the high incidence of malnutrition in this

sector of the population. Three ‘Nutrition Standards’

were drawn up: (1) to assess past and/or potential

difficulties in eating or drinking, (2) to enable the client

to eat or drink and (3) to monitor and evaluate the

nutritional status and nutritional care of clients. These

standards were formulated within a broad philosophy

which aimed to promote health by maintaining or

improving optimal nutritional status and to enhance

quality of life through eating and drinking. The guide-

lines were intended to heighten nurses’ awareness of the

role in ensuring adequate nutrition through eating and

drinking, clarify the roles of the multidisciplinary team

in relation to nutrition and provide a cost-effective

service by preventing unnecessary recourse to interven-

tions where adequate oral nutrition and hydration

would have been appropriate (RCN, 1993). These

standards, however, assumed that there was a provision

for nutritional education within the initial preparation

of registered nurses (RCN, 1993). In 1995 in the UK, the

Caroline Walker Trust (CWT), produced a report from

an expert working group on nutrition for residents of

care homes. It included an explanation of why nutri-

tional guidelines are needed, how a good diet can

contribute to the health of older people, information on

the nutritional requirements of older people, examples

of menues which meet guidelines for older people, advice

on undertaking nutritional assessments and ways of

improving the appetite of older people.

Despite the good intentions of the RCN (1993)

initiative and the recommendations of the CWT

(1995), it is apparent that the nutritional needs of many

ARTICLE IN PRESSD.T. Cowan et al. / International Journal of Nursing Studies 41 (2004) 225–237 231

older people are still not being recognised (Gariballa and

Sinclair, 1998; Copeman, 2000; Kayser-Jones, 2000;

Lauque et al., 2000), or met (Eberhardie, 2002; Tolson

et al., 2002). This is because nutritional assessment is

inadequate (Gariballa and Sinclair, 1998; Holmes, 2000;

Campbell et al., 2002; Jones, 2002). Furthermore, this

state of affairs continues despite the belief that many

cases of malnutrition and dehydration among older

people are preventable or at least treatable (Abbasi and

Rudman, 1994; Kamel et al., 1998; Noble, 1999; Lauque

et al., 2000). As Kayser-Jones (2000) summarised, while

adequate nutrition may only be one part of the total care

afforded to care home residents, in one sense it is the

most important. Kayser-Jones (2000) argued that if food

and water cannot be provided for these older people and

if they are allowed to become malnourished and

dehydrated, then what is the point of providing other

treatments such as medication or physical therapy?

A nursing best practice statement (BPS) regarding

nutrition for physically frail older people in the UK has

been developed to improve care (Tolson et al., 2002).

Tolson et al. (2002) noted that nurses have an essential

role to play in promoting adequate nutrition among

such vulnerable groups and that poor practice in

hospitals and care homes may be linked to expert

nurses’ diminishing input. The five-section BPS recom-

mends that nurses undertake nutritional assessment and

care planning, promote a nutritious diet, ensure the

environment is conducive to the enjoyment of meals,

manage the provision of food and drink and that they

forge links with other professionals to enhance nutri-

tional care (Tolson et al., 2002). In addition, Tolson et al.

(2002) recommended that nurses and support workers

receive education and training on nutrition for older

people.

In a recent report by the Malnutrition Advisory

Group (MAG) of the BAPEN, it was highlighted that in

developed countries, while sub-optimal nutrition is

common among hospital patients and older people

resident in care homes, it is frequently unrecognised and

untreated (MAG, 2000). In a more recent newsletter the

BAPEN (2002) noted the importance of raising aware-

ness about nutrition (BAPEN, 2002). A report by the

Royal College of Physicians (RCP) titled: Nutrition and

patients: a doctor’s responsibility (RCP, 2002) noted

that while nutrition is now high on the public agenda, it

is often overlooked by doctors (RCP, 2002). Professor

Sir George Alberti, president of the RCP, stated that the

report itself should be seen as a wake up call for the

medical profession to take clinical nutrition seriously

(RCP, 2002). The report recommended that nutritional

screening of all patients should be an integral part of

clinical practice and that primary care facilities, hospi-

tals and care homes should develop protocols and

standards to inform the whole process of nutritional

management (RCP, 2002). Hopefully some of the RCP

(2002) recommendations concerning care homes for

older people should be addressed within the require-

ments specified within the government’s national mini-

mum standards for care homes (DoH, 2002). These

standards include a requirement to make full nutritional

assessments of residents, to monitor changes in weight,

appetite and appearance and to provide a varied,

appealing, wholesome, nutritious diet in an attractive

manner, within unhurried mealtime periods in which

staff provide discreet, sensitive and individualised

assistance where necessary (DoH, 2002).

3.2. Detection

Research needs to be focussed on the development

and evaluation of adequate nutritional assessment tools

specific to older people with regard to the detection of

those older people with, or at risk of malnutrition. The

MAG (2000) undertook a systematic assessment of 23

screening tools/guidelines concerned with the detection

and management in the community. However, none

were found adequate for routine clinical practice in the

UK (MAG, 2000). While they recommended that nurses

complete initial and follow-up nutritional screening of

older people, Tolson et al. (2002) were unable to find an

appropriate screening tool specifically for use with frail

older people. Prior to this, also noting the absence of

such a tool, Guigoz et al. (1996) had introduced the Mini

Nutritional Assessment (MNA) for evaluating the

nutritional state of frail older people. This is an 18-item

test which involves anthropometric measurements,

general assessment questions, dietary assessment ques-

tions and subjective assessment questions (Guigoz et al.,

1996). In a review of the methodology of nutritional

screening and assessment tools however, Jones (2002)

found that of the tools reviewed, including the MNA,

none satisfied the imposed set of criteria for scientific

merit. These criteria included a requirement for the

inclusion of details regarding the method and time of

use, who should use the tool, and tool evaluation,

including both appropriate validation and reliability

testing of the tool (Jones, 2002). Jones (2002) concluded

that while a considerable amount of time and effort had

been expended on developing tools for the diagnosis of

malnutrition, no single paper was judged to have been

published with sufficient information regarding a tools

development, application and evaluation. In view of

Jones (2002) comments, it would appear that further

research is required into developing, applying and

rigorously evaluating nutritional assessment tools such

as the MNA. Furthermore, a tool intended for general

use will need to be reliable when used by a practitioner

with minimal training and equipment.

Gariballa and Sinclair (1998) and Holmes (2000) have

highlighted that nutrition screening tools lack sensitivity

and specificity. In this context, sensitivity and specificity

ARTICLE IN PRESSD.T. Cowan et al. / International Journal of Nursing Studies 41 (2004) 225–237232

can be defined as the performance rates, or discrimina-

tory power of a given tool or test (Open University,

1992). Sensitivity relates to the number of true positive

results identified by the test, compared to the number of

false negative results reported, while specificity relates to

the number of true negative results identified by the test

compared to the number of false positive results

reported (Open University, 1992). To be of maximum

benefit, any tool or test should be sensitive enough to

pick up all of the true positive results, while still being

specific enough not to pick up any false positive results.

This is not always the case in practice and in order to

develop such tests, a previously defined ‘gold standard’

test is required to verify the results of the tool or test that

is being developed (Open University, 1992). Again, in

practice, there is not always such a gold standard test in

existence and whether or not there is one for the purpose

of screening older people for malnutrition is still the

subject of debate.

Body mass index (BMI), has been described as the

gold standard test for defining nutritional status

(Pennington, 1998). A BMI of 19 or less signifies

undernutrition and a BMI of 25 or more signifies

excessive weight (Pennington, 1998). However, Penning-

ton (1998) has argued that reliance on the BMI and

other types of anthropometric measures, including mid-

arm muscle circumference and triceps skin-fold thick-

ness may be misleading as the impairment of organ

function may develop with nutritional depletion before

significant structural changes can be measured. Gar-

iballa and Sinclair (1998), Morely et al. (1998), Holmes

(2000) and Gerrior (2002) advocate caution in the use of

screening tools which include anthropometric measures

in older people. Furthermore, Morely et al. (1998) stated

that while BMI and other anthropometric measures are

commonly used in conjunction with biochemical mea-

surements to define the type and severity of malnutri-

tion, they should not be seen as a gold standard test.

Copeman (1999) also advised that biochemical test

results must be interpreted with care and Pennington

(1998) noted the unreliability of serum albumin testing

to define nutritional status, as normal serum concentra-

tions may be maintained in starving patients, for

example in anorexia nervosa, until the terminal phases

of illness. Evidence to support these views was recently

generated in a USA study undertaken by Covinsky et al.

(2002) in which they compared the serum albumin levels

of hospitalised older people ðn ¼ 311Þ with ratings fromthe Subjective Global Assessment (SGA). The SGA is

described as a systematic method comprising physical

examination and a nutrition orientated history, (record

of weight loss over prior six months, particularly during

the last 2 weeks) combined with clinical judgment, to

rate nutritional status of older people (Covinsky et al.,

2002). Covinsky et al. (2002) concluded that while both

serum albumin levels and the SGA were markers of

nutritional status, they were often discordant and

reflected fundamentally different clinical processes.

Furthermore, Kerstetter et al. (1992) and Gerrior

(2002) noted that methods used for assessing nutritional

status have largely been derived from and used in

conjunction with younger adults.

In view of the above, as Gariballa and Sinclair (1998)

have emphasised, more research is needed to produce

appropriate anthropometric reference data with ade-

quate consideration of age differences and data which

have been developed using sound experimental design

and adequate sample size. Echoing the misgivings of

Morely et al. (1998), Pennington (1998) and Copeman

(1999), Gariballa and Sinclair (1998) highlighted the

need for additional research to establish the true

magnitude of malnutrition and other extraneous causes,

such as acute illness, on biochemical markers such as

serum albumin levels. Furthermore, considering that

undernourished individuals can often be identified

visually, by simple clinical examination, particularly

when the condition is advanced, the value of taking

down an older person’s medical history combined with

physical examination as measurement of nutritional

status as opposed to objective measures yielding a

numerical score warrants further investigation (Gari-

balla and Sinclair, 1998; Holmes, 2000).

4. Education and training needs

Before the DoH (2002) national care home standard

requirements can be met, it is likely that many health

care professionals will require additional training and

education on nutrition, as has already been highlighted

in literature spanning the last three decades (Hill et al.,

1977; King’s Fund Centre, 1992; Nazarko, 1993; Perry,

1997; Pennington, 1998; MAG, 2000; RCP, 2002;

Sayhoun, 2002; Stanner, 2002). The RCP report

recommended extra training for medical undergraduates

and that continuing training programmes for doctors

should include relevant aspects of clinical nutrition and

consideration of the relationship between inappropriate

nutrition and health (RCP, 2002). Similarly, as the

British Nutrition Foundation (BNF) highlighted, nurses

and support workers employed in care homes for older

people will also need to undergo additional training

(Stanner, 2002). This is despite the earlier assumption

that nutritional education was being provided in initial

nurse preparation programmes (RCN, 1993). These

observations are supported by studies (Table 4), which

assessed nurses’ knowledge of nutrition in older people

(Stanek et al., 1991; Gaskill and Pearson, 1992;

Lindseth, 1994; Perry, 1997; Crogan and Shultz, 2000).

In an Australian pilot study to assess the relationship

between nurses’ assessment of nutritional requirements

of vulnerable hospital patients (n ¼ 7; age range 70–93

ARTICLE IN PRESSD.T. Cowan et al. / International Journal of Nursing Studies 41 (2004) 225–237 233

years) with actual nutritional intake, Gaskill and

Pearson (1992) found that approximately a third of

the time, nurses either overestimated or were unaware

of patients’ intake. Gaskill and Pearson (1992) con-

cluded that even modest changes in nurses’ attitudes

could reduce the prevalence of malnutrition among

vulnerable patients. In a UK survey of patient care plans

(n ¼ 141 documents), nurses ðn ¼ 110Þ drawn from

nine wards of a hospital, Perry (1997) found that

there were shortfalls among qualified nurses regarding

knowledge, communication and co-ordination necessary

to ensure adequate nutrition among patients. Perry

(1997) recommended that nurses could benefit from

enhanced education and insights into the interactions

between nursing knowledge, attitudes and activities both

within and between nurses. Building upon the work by

Stanek et al. (1991) and Lindseth (1994), Crogan and

Shultz (2000) undertook a study of USA care homes

ðn ¼ 5Þ: Crogan and Shultz (2000) found that nursesðn ¼ 44Þ and licensed vocational practitioners (LPNs)ðn ¼ 9Þ lacked sufficient knowledge of nutrition to beable to meet the dietary needs of the care home

residents. Crogan and Shultz (2000) recommended that

pre- and post-registration education needed to be

improved or in some cases provided, to increase the

quality of life for residents in care homes in a cost

effective manner.

Similarly, it has been noted that older people

themselves could benefit from greater awareness and

education regarding nutritional issues (Dwyer, 1993;

Mion et al., 1994; Davidhizar and Dunn, 1996;

Gariballa and Sinclair, 1998; Gerrior, 2002; Miller

et al., 2002; Sayhoun, 2002). Reflecting this, in a recent

10-week prospective study of older adults ðn ¼ 92Þ withtype two diabetes, Miller et al. (2002) found that

nutrition education improved metabolic outcomes that

had the potential to reduce levels of morbidity and

mortality among this group.

Research is needed into how best to design training

and educational programmes for health care personnel

involved with older people who are resident in care

homes. This includes more research into the nutritional

knowledge and attitudes of carers with a view to meeting

the nutritional needs of their clients. Educational

interventions need to be provided at vocational, under-

graduate and postgraduate levels. Furthermore, survey

research is needed to explore the knowledge and

attitudes of these health care staff with a view to

developing strategies to improve upon the current

situation. Specific research is also required into how

best to train carers of older people to make best use of

current nutritional assessment tools (Holmes, 2000).

Reflecting Jones’ (2002) concerns regarding lack of

detail about who should use assessment tools and when,

Holmes (2000) warned that no tool, regardless of

validity, is useful in untrained hands. It should also be

noted that unqualified staff comprise the majority of

carers of older people.

Research is also needed to determine how best to

educate older people regarding their own attitudes to

nutrition and ageing, as well as enabling older people

to be facilitative partners in the management of their

nutritional status. Training and education for health

care professionals should aim to impart awareness that

the prevalence and risk of malnutrition among older

people, especially those in care homes is likely to be

significant. However, to facilitate this, additional re-

search is also needed into the detection and prevalence

of malnutrition and other nutritional problems in this

sector.

4.1. Remedies for malnutrition and maintenance of

nutritional status

The development of a comprehensive body of

research in this area should serve to improve the scope

for remedial interventions and enhanced maintenance of

the nutritional status of older people resident in care

homes. Reflecting this, Gariballa and Sinclair (1998)

suggested that adequate training and education of health

care staff would serve to maintain and improve the

nutritional status of older people. Also, in conducting

research into the causes and effects of malnutrition it is

likely that remedies for such will be formulated. For

example, if prospective studies demonstrate that deple-

tion of certain vitamins causes or contributes to certain

types of dementia, then clearly, adequate supplementa-

tion of those vitamins can be utilised as a remedial

intervention and continued use of these supplements

should serve to lessen the risk of relapse. Also research is

required into how best to develop and implement

guidelines for standardisation of monitoring nutritional

status across care homes (Barr, 2002). Furthermore, in

order to effectively educate the relevant health care

professionals, the suggested research into determining

the prevalence, the best methods of detection and the

causes and effects of malnutrition should inform future

training and educational programmes for these carers.

5. Interim measures

It has been previously noted that there was an urgent

need for routine assessments of the nutritional profile of

older people or of the adequacy of food provision in the

UK and that health care staff working with older people

to have access to and be able to use simple assessment

techniques to identify those older people who may be at

risk from malnutrition (Caroline Walker Trust, 1995).

This remains the case as recent reports indicate (MAG,

2000; BAPEN, 2002; Campbell et al., 2002; RCP, 2002).

ARTICLE IN PRESSD.T. Cowan et al. / International Journal of Nursing Studies 41 (2004) 225–237234

In view of this situation and in the absence of more

sophisticated tools, some form of interim measure is

needed. In a USA study to clarify the clinical

significance of weight among older people ðn ¼ 5677Þaged 55–74 years, over a 8.7 year period, Tayback et al.,

(1990) found that among men aged 55–74 years and

women aged 65 to 74 years, a BMI of less than 22 was

associated with elevated mortality rates, with an added

risk factor of between 30 and 60%. They associated this

with underlying illness, heavy alcohol use and poor

nutritional status. The authors concluded that more

attention be afforded to weight-associated risks among

older people at the low end of the BMI continuum

(Tayback et al., 1990). The findings of this study indicate

that despite the earlier mentioned doubts around the

BMI measurement being perceived as a gold standard

test, in the absence of anything else, routine initial BMI

measurement and ongoing monitoring is useful in

identifying risk in older people and would be a

significant improvement on the current situation in care

homes.

Despite the lack of appropriate anthropometric

reference data with regard to older people (Kerstetter

et al., 1992; Gariballa and Sinclair, 1998; Gerrior, 2002),

BMI measurement has been supported by Kloster Yen

(1992) and Dwyer (1993) who believed height and trends

in weight over time, to be the most useful anthropo-

metric measures. McWhirter and Pennington (1994) also

advocated that anthropometric measurements are

cheap, simple, not time-consuming and technique

improves with practice. Similarly, Morely et al. (1998)

stated that weight loss is one of the best indicators of

poor outcome and nutritional risk in nursing homes.

Further, despite problems of controlling for changes

influencing body composition and biochemical para-

meters that are associated with ageing (Kerstetter et al.,

1992; Gariballa and Sinclair, 1998), Kerstetter et al.

(1992) recommended that after initial baseline measure-

ment, an older person may be compared with themselves

over time, thus expressing change as a percentage of

usual or previous measurement which can provide a

useful basis for nutritional assessment. Similarly, Pen-

nington (1998) recommended regular assessment of

weight loss, Davidhizar and Dunn (1996) noted that

an accurate record of weight loss is the most valuable

measurement in assessing nutritional status and Sullivan

et al. (2002) recently noted that continued weight loss

among older people in long-term care appeared to have

ominous implications for mortality. Mion et al. (1994),

while noting that skinfold results should be interpreted

with caution in older people due to changes in

consistency of tissue as compared to younger adults,

advised that weight and height are the cornerstone of

nutritional assessment. Such an approach can be

complemented with an interdisciplinary team approach

combining the skills of physicians, nurses, dietitians and

various other therapists to assess the older person’s

capacity to access and consume adequate nutritional

intake (Kerstetter et al., 1992).

Following their review of tools, The MAG (2000)

developed their own screening tool for adults at risk of

malnutrition. This tool, which has been tested for

validity, reproducibility and reliability, incorporates

three steps (MAG, 2000). Step one involves the subject’s

BMI measurement, step two involves assigning the

subject to a weight loss category (>10%, 5–10% or

o5% bodyweight) as observed over three to six months

and following calculation of the overall risk category of

the subject, based on BMI status and weight loss, step

three involves determining a clinical care plan depending

on the subject’s risk category. If there is difficulty in

obtaining height or weight measurements then questions

are recommended on the following: history of decreased

food intake, loss of appetite; dysphagia; items of

clothing or jewellery that have become loose fitting;

and psychological or physical disabilities that have

contributed to weight loss. From this, the MAG have

now further developed the Malnutrition Universal

Screening Tool (MUST), the main report of which,

summarising evidence of reliability, ease of use and

application to different situations, is expected to be

published this year (Elia, 2002).

Pending the implementation of findings of future

research, in the interim, recommendations by Copeman

(2000) and more recently, Blades (2002) should serve as

a useful set of guidelines with regard to addressing the

individual and organisational factors associated with

malnutrition among older people resident in care homes.

6. Conclusion

Despite the progress of biomedical science, in the 21st

Century, malnutrition remains a significant problem not

only in the developing countries but also in the

developed world (MAG, 2000), in particular so among

older people (Elmstahl et al., 1997; Finch et al., 1998;

Copeman, 2000; Crogan and Shultz, 2000; Neel, 2001;

Eberhardie, 2002; Howell, 2002) and particularly those

in care homes (Morely et al., 1995; Crogan et al., 2001;

Neel, 2001). Ironically, malnutrition among this popula-

tion appears to persist as a problem despite being

preventable and/or treatable (Dwyer, 1993; Abbasi and

Rudman, 1994; Morely et al., 1995; Hosam et al., 1998;

Kamel et al., 1998; Noble, 1999). Most of the issues

raised in contemporary publications are not new. The

same issues have been regularly acknowledged in the

developed world for over a quarter of a century (Hill

et al., 1977; Cutler, 1986; Goodwin, 1989; Lehmann,

1989; Dwyer, 1993; McWhirter and Pennington, 1994;

Davidhizar and Dunn, 1996; Copeman, 1999). Despite

this, the nutritional needs of many older people are still

ARTICLE IN PRESSD.T. Cowan et al. / International Journal of Nursing Studies 41 (2004) 225–237 235

not being recognised (Gariballa and Sinclair, 1998;

Copeman, 2000; Kayser-Jones, 2000), or met (Eberhar-

die, 2002; Tolson et al., 2002) partly because nutritional

assessment is inadequate (Gariballa and Sinclair, 1998;

Holmes, 2000; Campbell et al., 2002; Jones, 2002).

In response to these problems in the UK, the

government has pledged to provide high-quality, cost-

effective health care and treatment for this sector of the

population (DoH, 2001) which includes minimum

standards to ensure their nutritional needs (DoH,

2002). This will require improved and additional

training and education on nutrition for doctors, nurses

and support workers at vocational, undergraduate and

postgraduate levels. Research is needed to inform how

best to provide such training and education as is

research to enable effective detection of malnutrition,

to properly assess the prevalence of malnutrition among

older people in care homes together with research

regarding the causes, effects, prevention and treatment

of malnutrition in this vulnerable yet expanding sector

of the population. Research is also needed to inform

how older people themselves may benefit from improved

knowledge of their nutritional needs.

Over the years there have been numerous calls for

research into the area of nutrition in older people in the

developed world (Goodwin, 1989; Kloster Yen, 1992;

Nazarko, 1993; Abbasi and Rudman, 1994; Sullivan,

1995; Gariballa and Sinclair, 1998; Masaki et al., 2000;

Gonzalez-Cross et al., 2001; Gerrior, 2002; Miller et al.,

2002; Sayhoun, 2002; WHO, 2002). Commenting that

while significant numbers of older people in care homes

are particularly vulnerable to sub-optimal nutrition and

malnutrition, Nazarko (1993) called for research into

the epidemiology of these states in this sector of the

population. Abbasi and Rudman (1994) noted that

following the second world war there were frequent

comments in the literature concerning problems of

under-nutrition among older people and called for

research to improve methods of recognition, prevention

and treatment of these problems. However, Garrow

(1994) has suggested that in the same period, nutri-

tionists became complacent about malnutrition and as

molecular biology became the priority for research

funding, malnutrition was perceived as something that

only affected developing countries. Furthermore, as the

solutions to nutritional problems are often straightfor-

ward, requiring what may be termed as low-technology

interventions, they may not necessarily excite the interest

of the scientific community (Goodwin, 1989; Kerstetter,

1992).

If, as the BAPEN (2002) advocate, nutrition is to be

pushed higher up the agenda in the UK then the

research that has been called for so long, is now required

as a matter of urgency. Pending the outcome of such

research, in the interim, simple measures such as

monitoring older people’s weight over time (Davidhizar

and Dunn, 1996; Pennington, 1998), need to be imple-

mented without delay.

7. Uncited reference

De Groot et al., 1999.

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