By Nell Lake
After her stroke, a 95-year-old woman in New York State found that she could no longer taste her food. She was also unable to feel hunger, so she didn’t know when she was supposed to eat. As a result, the woman began losing weight, grew weak and wasn't getting the nutrients she needed.
Enter Meals on Wheels, a national home-delivered meals program established by the 1965 Older Americans Act. The woman (who asked that her name not be used) began receiving meals at her home five days a week. This, she says, helped her remember to eat regularly. Her weight improved, and so did her general health.
Malnutrition like hers is surprisingly common. Six percent of the elderly who live at home in the United States and in other developed countries are malnourished, according to a 2010 study in the Journal of the American Geriatric Society. The rate of elder malnutrition doubles among those in nursing homes, where it is 14 percent, according to the same study.
And rates skyrocket among elderly populations in rehabilitation facilities and hospitals: Various measures show an astonishing one third to one half of seniors are malnourished upon being admitted to the hospital.
“Malnutrition is a serious and under-recognized problem among older adults,” says Nancy Wellman, a nutritionist and instructor at Tuft University’s Friedman School of Nutrition Science and Policy.
It's not a new problem. But growth in the elderly population, and concerns about healthcare costs, have helped renew efforts by nutritionists and other advocates to establish screenings for malnutrition in medical settings, and to improve interventions that can prevent or reverse the issue.
Most basically, malnutrition means not getting enough nutrients for optimal health. In older adults, the causes are complex, experts say. Illness, disability, social isolation, poverty — often a combination of these — can all contribute to malnutrition. An older person may become malnourished because she has trouble chewing or swallowing. The medications she takes may suppress appetite. She may be unable to get to a grocery store. She may live alone, be depressed, or simply be uninterested in eating.
It’s important to know, says Connie Bales, a dietician and faculty member at Duke University Medical Center, that obese and overweight seniors can be malnourished, too. Eating too many calories doesn’t necessarily mean you’re getting the right nutrients for maintaining muscle and bone. “One can be quite malnourished, yet not be skinny,” Bales says.
Whatever the cause, malnutrition leads to further trouble. It increases older adults’ risk of illness, frailty and infection. Malnourished people visit the doctor and are admitted to the hospital more often, have longer hospital stays and recover from surgery more slowly.
The association between malnutrition and hospitalization goes both ways, say Wellman and other experts: The sick are more likely to become malnourished, and the malnourished are more likely to get sick.
Thus, says elder advocate Robert Blancato, speaking at a recent panel on the topic, improving nutrition among older people is important not just to their well-being and quality of life, but to containing health care costs. The malnourished generate bills $2,000 to $10,000 higher per hospital stay than others do, according to a study in the Journal of the American Dietetic Association.
Another study published in the journal Clinical Nutrition found a threefold increase in medical costs among the malnourished. (Hospital stays can also cause or worsen elder malnourishment: Older patients often don’t eat well in the hospital, and doctors may prohibit them from eating or drinking in preparation for medical procedures.)
Not surprisingly, financial hardship is a central cause of elder malnutrition. According to a 2014 report from the AARP Foundation, nearly 9 million older people in the U.S. can't afford nutritious food. About one quarter of low-income adults 65 and older say they’ve reduced the size of their meals or have skipped meals because they didn’t have enough money.
Jeffrey Bubar might have been among them — his fixed income places him barely above the federal poverty line. Yet he’s well fed.
Earlier this week, Bubar, 76, dug happily into a plateful of sloppy Joe, baked potato and vegetables. He chatted with four other elderly men, also regulars at a Congregate meals program in Northampton, Massachusetts -- one of hundreds of such programs across the country. (Another provision of the Older Americans Act.)
Bubar -- who has no family, lives alone and has no car -- walks to the program every weekday. The meals provide him with both companionship and nourishment — sources of health and well-being that would otherwise likely elude him. “I like being with people,” he says.
His fixed income places him barely above the federal poverty line. Without the meals, food would make a much bigger “dent” in his budget, he says; and the program’s nourishment “helps keep my health up.” It’s a nutritional and social anchor in his otherwise isolated life.
But many eligible seniors don’t receive such benefits. The AARP report, for example, found that of those elders eligible for the Supplemental Nutrition Assistance Program (SNAP), only 13 percent receive the benefit. It’s an important gap to address, says Lura Barber, director of Hunger Initiatives for the National Council on Aging, and there are many reasons for it. One is that “there’s a huge stigma attached to [food benefits],” she says. Older people worry, for example, that by receiving help they’ll take benefits away from children who need it. But “seniors are also less likely than other age groups to know about the program, about how to apply, and [to know] that they might be eligible.”
Following hospital stays, these programs could also help patients recover from illness or surgery. And yet very few hospital patients receive information about nutrition benefits. A recent survey by the Gerontological Society of America found that only 6 percent of hospitalized elderly received information about SNAP. Only 3 percent of hospitalized older people received information about group meals programs such as the one Bubar benefits from. And only 3 percent learned about the availability of delivered meals to home-bound seniors.
Good Nutrition, Better Outcomes
Such lack of information is another problem worth addressing, Barber says. “There’s a huge gap in how we’re providing vulnerable older adults with help as they move from a healthcare setting” back to their homes. Even those simply “going to a doctor for a regular visit are not learning about [nutrition] programs.”
Rose Ann DiMaria-Ghalili, a nurse and researcher with Drexel University’s College of Nursing, says better nutrition can improve hospital outcomes and reduce hospital readmissions. “We know,” she says, “that weight loss increases the risk of 30-day readmission,” she says. “And that failure to thrive and weight loss are frequent reasons for readmission in surgical patients.”
Nancy Wellman says, “If you can’t eat well, you’re going to end up in a nursing home, or you’re going to end up back in the hospital.”
Given mounting evidence that better nutrition in both older patients and seniors living at home is a cost-effective way to improve health outcomes—not to mention quality of life—Wellman and others call for several manageable fixes:
“We should be thinking about nutrition as one of the key aspects of healthy aging, of maintaining our independence, maintaining our quality of life, staying out of nursing homes, and staying out of hospitals,” Wellman says. She and other advocates urge individuals, community programs, medical professionals, and policymakers to learn about and prioritize nutrition as an important and relatively inexpensive way of improving health.
Nutrition Screenings And Interventions
Including nutritional status and nutrition interventions in patients’ plan of care would promote better outcomes, says DiMaria-Ghalili. And Wellman says, “We need to establish systematic screenings and intervention models” for patients entering and leaving the hospital. Connie Bales of Duke Medical Center argues that doctors and nurses could usefully view patients’ nutritional status as a vital sign, as they do blood pressure or temperature: “We know what [a patient’s] pulse rate is, what their respiration rate is,” Bales says. “What about their nutritional status?”
Access To Benefits
Barber would like to see nurses routinely asking elderly patients whether they’re receiving nutrition benefits, and referring them to meals programs and SNAP where appropriate. Nurses or other staff, she says, could also help older patients fill out applications for benefits before patients leave the hospital.
Finally, Wellman offers basic advice to older adults: “Bring home more fruits, more vegetables, some low-fat dairy...or full-fat milk if you’re underweight. Bring home prepared or prepackaged food, because it’s more likely that you’ll eat it.” If foods aren’t appealing, try adding more spices to enhance taste. If you’re overweight but ill, she says, it’s often better to prioritize eating well over losing weight. And if possible, seek out company: “People eat better when they’re with other people,” Wellman says.
On Monday, Bubar was looking forward to joining his friends at the Congregate program for the Thanksgiving meal. He’d already checked out the menu: “It’ll be turkey and whipped potatoes and butternut squash,” he said. He expected that the program’s cook would make the pies right there in the kitchen, so Bubar was eagerly anticipating house-made pumpkin pie with whipped cream.
Nell Lake is the author of "The Caregivers: A Support Group’s Stories of Slow Loss, Courage, and Love." This article was written with support from the Journalists in Aging Fellowships, a program of New America Media and the Gerontological Society of America, sponsored by the Silver Century Foundation.