Anorexia of Aging: Page 4 of 4

October 6, 2011

Assessing Nutritional Status in LTC Residents

The ADA defines nutritional assessment as “a systematic process of obtaining, verifying, and interpreting data in order to make decisions about the nature and cause of nutrition-related problems.”4 CMS requires LTC facilities to assess every resident’s nutritional status as part of the Resident Assessment Instrument (RAI), and develop a care plan for individuals at risk of undernutrition. Several other more detailed assessment tools are available and should be used
to supplement the RAI when appropriate.4 Despite the availability of these assessment tools, Volkert and colleagues32 found significant inconsistencies between the presence of malnutrition in patients admitted to a geriatric hospital ward and its diagnosis by physicians and nurses.

A complete nutritional assessment often requires an interdisciplinary team that includes caregivers in a position to observe the resident during mealtimes, the resident or his or her representative, and healthcare practitioners.4 Other experts who might need to be part of the team are a registered dietician (if on staff),5 a speech pathologist to investigate swallowing issues, a psychologist if depression is suspected, and a pharmacist.4,33

Signs of Undernutrition
Measuring height and weight is the least invasive way to assess nutritional status and allows BMI to be calculated. In the LTC setting, it is important to weigh residents at admission to establish a baseline weight, then weekly for 4 weeks and monthly thereafter.4 Studies differ on the ideal BMI for adults aged ≥65 years, but most agree that a BMI of <18.5 kg/m2, which is considered underweight in adults,34 is inadequate for assessing the nutritional status of elderly adults. Volkert and colleagues32 identified a BMI of <22 kg/m2 as indicative of malnutrition in adults aged ≥65 years.32 Other studies35 have found higher mortality rates in elderly individuals with a BMI <25 kg/m2, which suggests that more research is needed to determine the usefulness of BMI in detecting malnutrition in the elderly.

Other indicators of nutritional status include overall appearance; condition of the hair, nails, and skin; oral health; and behavior, such as degree of responsiveness or lethargy.4 Laboratory values, such as serum albumin levels, may point to possible malnutrition but should be followed with a more thorough assessment.4

Screening Instruments Validated for Geriatric Use
The Mini Nutritional Assessment (MNA) is a validated, reliable instrument specifically designed for use in older adults and should be included in a comprehensive geriatric assessment.36 Using the MNA, Kaiser and colleagues37 found a high prevalence of malnutrition in a select group of elderly patients and, due to the tool’s geriatric focus, recommended it form the “the basis for nutritional evaluation in older people.”The MNA has also been shown to help predict mortality risk.10

The approximately 15-minute test contains 18 items, including height, weight, mobility, lifestyle, circumference of the arm and calf, weight loss during the previous 3 months, eating and drinking habits, medication use, presence of pressure ulcers, ability to feed oneself, and the patient’s perception of his or her health and nutritional status.38 A maximum of 14 points are possible, with a score of 12 to 14 points indicating “normal nutritional status,” 8 to 11 points indicating “at risk of malnutrition,” and 0 to 7 points indicating a patient who is malnourished. The MNA short form was recently released, which consists of six questions and is available at no cost for the iPod and iPhone.

Another reliable assessment tool for malnutrition risk is the Sadness, Cholesterol, Albumin, Loss of Weight, Eating, and Shopping (SCALES) test.10 SCALES was designed for outpatient screening and combines a subjective assessment with laboratory results to determine malnutrition risk. Variables considered include a score of >15 out of 30 on the Geriatric Depression Scale, cholesterol concentration <4.14 mmol/L, an albumin concentration of <4 g/L, a loss of 2 lb of body weight in 1 month or 5 lb in 6 months, difficulty feeding oneself, and the ability to buy and prepare meals.42 A score of 3 or higher is an indication of malnutrition.43 Thomas and associates42 performed a study in a subacute care setting and eliminated shopping because it did not apply to the population.42 They discovered SCALES, without the shopping assessment, is a useful tool in determining malnutrition risk. By eliminating the shopping question, the SCALES assessment would be an appropriate tool for patients in LTC.

The Geriatric Nutritional Risk Index (GNRI) is used to evaluate risk of nutrition-related problems. Like the MNA, the GNRI contains anthropometric components such as height, weight, triceps skinfold, and arm circumference, but it adds nutritional markers, including albumin, prealbumin, and total lymphocytes.39 A GNRI score <92 indicates high risk, 92 to 98 is moderate risk, and >98 is no risk. In comparing the GNRI with the MNA in 241 institutionalized elderly residents, Cereda and colleagues39 found poor agreement between the two assessments regarding nutritional
status and concluded that the GNRI was better than the MNA at predicting nutrition-related complications. The researchers noted that since the GNRI was newer than the MNA and the MNA had several studies attesting to its validity, combining the two would be the best option for predicting nutrition-related outcomes.39

These tests can be performed by the resident’s primary care provider (physician or nurse practitioner), or by a registered dietician. It is important that whoever is performing the assessmment is familiar with the tool, so they do not come to an incorrect conclusion.

Care Plan

Whatever method of assessment is used, once a resident has been identified as being at risk for undernutrition or as malnourished, a care plan must be developed. In addition to some of the previously discussed interventions, practitioners will want to weigh the need, benefits, and risks of medical treatment, nutritional supplementation, or even feeding tube use. Many older individuals are set in their ways, and it can be difficult to change their daily routines. Practitioners should consider the individual’s current eating habits and preferences when developing a care plan.

Once interventions have been implemented for patients with unplanned weight loss, frequent monitoring of their effectiveness is important. Patients should be weighed weekly until their weight stabilizes or improves. The care plan should be updated as the patient’s status changes, when new interventions are tried, or to reflect new goals.4

Appetite Stimulants
Current evidence does not support using appetite-stimulating medications to treat unintentional weight loss in older adults, although CMS notes their use may be appropriate in limited circumstances.4 Trials involving dronabinol, megestrol acetate, and recombinant growth hormone have reported serious treatment-related adverse effects, and these agents are not recommended for regular clinical use, especially in frail elders.40

Nutritional Supplementation
Nutritional supplementation has been shown to improve caloric intake among individuals with anorexia of aging, reducing their risk of malnutrition.10 Payette and associates41 found that providing nutrient-dense, protein-energy liquid supplements to frail elderly people who were undernourished and losing weight significantly improved their nutritional status and arrested or reversed weight loss. Another study reported weight gain and a 34% reduction in mortality risk with oral nutritional supplementation.40

Timing of nutritional supplementation is important, because it may cause the patient to eat less during mealtime. Studies indicate that consuming nutritional supplements between meals, rather than with meals, is associated with greater improvement in caloric intake. It may also help to administer nutritional supplements at the time medications are given.4

Feeding Tubes
Feeding tubes may be an option for some patients, such as those with dementia or nearing the end of life, but the resident’s preferences must be considered and respected. CMS notes that tube feeding has not been found to extend or improve quality of life in patients with dementia.4


Anorexia of aging and PEM are major concerns among the aging population and especially in LTC. Unintentional weight loss in an elderly nursing home resident must be taken seriously because it increases the risk of morbidities, such as pressure ulcers, diminished cognitive and physical function, and falls; raises the likelihood of hospitalization; and is associated with an elevated risk of mortality.

Although many of the age-related physiologic, pathologic, sociologic, and psychologic changes associated with PEM are inevitable, PEM is usually preventable and should not be considered part of the normal aging process. Avoiding poor—and often costly—outcomes associated with undernutrition depends on identifying LTC residents at risk, conducting a proper nutritional assessment, and promptly taking any necessary preventive or corrective measures. Facilities would also benefit from adopting mealtime practices that enhance enjoyment of eating for all residents. While it is important to educate residents on good nutrition, these conversations should deemphasize food restrictions and seek to encourage healthy, sufficient food intake.

The author reports no relevant financial relationships.

Ms. Champion is a registered nurse and a master’s-level student, University of Pennsylvania, Philadelphia, PA.


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