Malnutrition and seniors: When a relative doesn't eat enough

At 82, your aunt is still beautiful, with a slender build and great charm. Active and outgoing, she recently moved to a retirement community where she hikes, plays bridge, and entertains her fiance and large extended family. By all objective measures, your aunt is thriving, but in fact, like many older Americans, she's malnourished.

According to some estimates, as many as 85 percent of adults in long term care facilities and more than half of all seniors cared for at home suffer from undernutrition or malnutrition — low or dangerously low levels of protein and other nutrients. But a growing number of active, independent older adults also are malnourished, especially women who live alone, minorities and low-income seniors. Experts say that spotting people who are clearly in trouble — those who are losing weight and muscle tone or becoming weak and confused — isn't difficult. The real challenge is identifying people who appear well nourished but aren't.

Tracking the causes of malnutrition

At first glance, the causes of malnutrition seem straightforward: too little food, a diet lacking in nutrients or absorption problems. But malnutrition is much more complex, a web of physical, emotional and social problems that traps vulnerable people in a self-perpetuating cycle of dependence and declining health.

For instance, older single adults, even energetic and self-sufficient ones like your aunt, often don't cook for themselves; unless invited out, their typical dinner may be nothing more than a handful of popcorn or a cup of tea. Carried on for long, a nutrient-poor diet accelerates the loss of muscle mass and strength that normally comes with aging. Shopping and preparing food become more difficult, which reinforces the tendency to subsist on easy but empty fare — toast, cold cereal, saltines. Eventually, the chronic lack of nourishment leads to increased frailty and dependence, which in turn can trigger depression — itself a major drain on appetite.

Malnutrition weakens the immune system, increasing the risk of pneumonia and other serious infections and exacerbating existing health conditions. And it can also contribute to mental confusion. Very ill or disorientated people are unlikely to eat well, if at all, and they're more likely to end up in a hospital or long-term care facility, where they're vulnerable to pressure sores, infections, post-surgical complications and further malnutrition.

When does malnutrition begin?

If the scenarios are complicated, so are the factors that lead people to eat poorly in the first place. Often, the trigger isn't a single event, but a cascade of difficulties, many of which are common among people who are aging:

• Chronic illness. Older adults may have debilitating, long-term conditions that affect their ability to shop, prepare meals or feed themselves. What's more, both chronic and acute ailments often suppress the appetite even as they increase the body's need for nutrients. Dementia, Alzheimer's disease, alcoholism and other illnesses that affect mental functioning also have a profound influence on appetite and on the capacity to prepare and eat healthy meals. Caregivers also are often at risk, neglecting themselves while they tend an ailing partner.
• A recent hospitalization or nursing home stay. Acute illness or surgery can take a tremendous toll on the health of seniors, often resulting in loss of appetite, weakness, weight loss and debilitation.
• Depression. Although frequently unrecognized and underreported in older adults, depression affects as many as 6 million Americans over 65, including more than a third of those in nursing homes. As with other aspects of aging, the reasons for depression are complicated and interrelated: grief, loneliness, isolation, failing health, retirement, lack of mobility, concurrent illnesses such as Parkinson's disease, cancer, or diabetes, medications and malnutrition itself, which makes depression worse.
• Alcoholism. It's not clear how many older adults have alcohol-related problems, but experts say the number is far larger than suspected even a decade ago. And alcoholism is a leading contributor to malnutrition — decreasing appetite, destroying vital nutrients and frequently serving as a substitute for meals.
• Malabsorption. Some of the physiological changes that occur with aging affect the way the body absorbs and uses nutrients. In many older adults, the production of certain digestive enzymes and acids diminishes, interfering with protein breakdown and with the absorption of vitamin B12, folate, and possibly calcium and iron. Lack of vitamin B12 can have a devastating effect on the nervous system, leading to an unsteady gait, muscle weakness, slurred speech and psychosis — signs and symptoms similar to those of such age-related diseases as Parkinson's and Alzheimer's. Other illnesses — cancers of the gastrointestinal tract, inflammatory bowel disease and even diarrhea — can interfere with absorption.
• Medications. Many drugs commonly prescribed for older adults can contribute to malnutrition by suppressing appetite, altering the way food tastes, causing nausea and vomiting, or interfering with absorption. Offending drugs include some antidepressants, certain blood pressure and osteoporosis medications, and even common analgesics such as aspirin. The problem is often compounded because many older people take several medications, all of which may affect the ability to eat and digest nourishing foods.
• Difficulty chewing and swallowing. Dental problems, including gum disease, cavities and poorly fitting dentures can affect the taste of food and make chewing nearly impossible. When people with chewing problems do eat nutritious foods, they may have trouble digesting them. A dry mouth — a side effect of many drugs — and diseases such as Parkinson's that affect the nervous system can interfere with swallowing.
• Diminished taste and smell. For most people, food is as much about comfort and enjoyment as it is about survival, and this may be especially true as people age. Yet taste and smell often diminish later in life, robbing food of much of its flavor. Although some sensory loss seems to be a normal part of aging, certain medications and diseases can make matters worse, especially Alzheimer's, which affects the pathways in the brain related to the sense of smell.
• Restricted diets. Seniors are more likely than any other group to have dietary restrictions, including limits on salt, fat, protein and sugars. Although such diets play a central role in managing many medical conditions, they can be so bland and unappealing that older adults simply stop eating. For that reason, some nutrition experts recommend rethinking restrictive diets, noting that malnutrition is more detrimental to overall health than rich or salty foods are.
• Limited income. Some seniors with limited incomes go hungry, especially if they're taking expensive medications. It's not uncommon for older adults to have to choose between drugs and groceries at the end of the month when Social Security checks are stretched thin.
• Loneliness and isolation. One of the biggest contributors to malnutrition is a solitary life and the loneliness, depression, grief, boredom and fear that often go along with it.

What to look for

The signs of malnutrition are often hidden, especially in people who don't seem at risk. To help uncover problems before they become more serious:

• Quiz older people about what they eat, but don't rely on self-reports alone. Try to spend time with them during normal meals at home, not just in restaurants or on special occasions. If you have an older friend or family member in a hospital or long term care facility, make a point of visiting during mealtimes. When you're concerned about weight loss, request a calorie count from the hospital or nursing home dietitian.
• Look for physical problems such as poor wound healing, easy bruising and dental difficulties.
• Know what drugs older family members take and how they affect appetite and digestion. Many commonly prescribed medications can reduce hunger and prevent nutrient absorption.
• Ask an older person's doctor to check certain protein levels (serum albumin, prealbumin or retinol binding protein levels). Despite some drawbacks, these tests can often help identify chronic malnutrition.

What you can do

Malnutrition is a complex problem, but the solutions can be surprisingly simple. Even small changes make a big difference in an older person's health and well-being:

• Enrich spartan diets. To boost nutrition, encourage seniors to spread peanut or other nut butters on toast and crackers, on fresh fruits such as apples and bananas, and on raw vegetables. Other suggestions include sprinkling nuts or wheat germ on yogurt, fruit and cereal; adding extra egg whites to scrambled eggs and omelets; and melting cheese on sandwiches, vegetables, soups, rice and noodles.
• Restore life to bland food. Try to make special diets more appealing by using lemon juice, herbs and spices and by varying the texture, color and temperature of foods. If loss of taste and smell is a problem, experiment with strong seasonings and flavors. Careful chewing can sometimes increase enjoyment because more flavor molecules come into contact with taste receptors. A dietitian can also suggest ways to perk up dull meals.
• Plan between-meal snacks. This can be particularly helpful for people who get full quickly. A piece of fruit or cheese, a spoonful of peanut butter, even a milkshake for people who aren't lactose intolerant can add nutrients and calories.
• Use nutritional supplements. Undernourished seniors are especially likely to be deficient in protein, vitamins B-6 and B-12, folate, niacin, vitamin D, calcium and zinc. Supplements are important because they can help supply missing nutrients, but they can't provide protein or needed calories and shouldn't become a substitute for meals.
• Consider outside help. If an older adult is very frail, consider hiring a home health aide to help prepare meals or investigate Meals-On-Wheels and other community services, including home visits from registered dietitians. Local churches and civic groups often have volunteers willing to shop and cook for seniors who live alone. Your department of health or community hospital can usually provide information on programs in your area.
• Engage doctors. Talk to doctors about changing medications that affect appetite and nutritional status and about screening for nutrition problems during routine office visits. Be sure to inform doctors if you notice that an older adult is losing weight. And consult a dentist about oral pain or chewing problems.
• Make meals social events. This may be the most important step in curbing malnutrition; older people clearly do better when they have company. Drop by during mealtime or invite seniors to your house. Or try eating out on a regular basis, which can boost spirits along with appetite. Take advantage of discount meals at earlier hours, and ask for small portions of food. If you can't share meals with the older adults in your life, encourage them to join programs where they can eat with others or arrange for them to have meals with friends. In one study, older adults who attended nutrition classes improved their nutritional status, but the change seemed to result from the social interaction the classes provided, not from the information they received.
• Encourage regular exercise. Many seniors, even those with serious health problems, can benefit from daily exercise — it stimulates appetite, helps depression, and strengthens bones and muscles. Exercising with others also provides motivation and social interaction.

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