Malnutrition: The New Senior Crisis

This week, September 28-October 2, 2015, is Malnutrition Awareness Week. It is an opportunity to spotlight a growing but under-recognized problem facing older adults in America: the hidden epidemic of malnutrition. What is malnutrition? Simply stated, it means poor nutrition. It is related to an excessive or imbalanced diet, a diet that lacks essential nutrients, or it can be tied to clinical conditions that impair the body's absorption or use of food.

Much attention is properly directed on issues related to senior hunger and food insecurity among older adults. However, malnutrition is an even more consequential problem for its victims and for our nation. Estimates are that disease-related malnutrition costs the U.S. a whopping $157 billion annually. Further, malnutrition creates a 300 percent increase in healthcare costs.

We also know that one in three hospital patients are malnourished upon admission and almost one-third of U.S. patients (31 percent) experience declines in nutrition status during their hospital stay. Malnutrition increases length of hospital stays on average by 4 to 6 days. Further related to malnutrition is sarcopenia (loss of muscle mass) which is now linked to a higher risk of falls in older adults.

As the problems associated with malnutrition become better known, we must provide better solutions, especially for the older adult. For example, we should promote better nutrition education so that older adults are aware that consuming enough calcium, Vitamins D and B12 will help reduce the risk of falling.

In our hospitals we need to change practices and promote more accountability for malnutrition from what is done upon admission through screening and assessment all the way through hospital treatments and interventions to discharge, so as not to have nutrition-related issues lead to a readmission in 30 days or less.

To start, we must promote more and better nutrition screening using a validated tool for all patients 65 and over who are admitted to the hospital. We must perform more and better assessments using a validated tool for all patients but especially older adults who are identified as malnourished or at risk of malnutrition. We must have documentation of a malnutrition diagnosis for all patients, especially older adults who are identified as malnourished or at risk of malnutrition. Finally, we need to establish and implement a malnutrition treatment plan including intervention and monitoring for these same patients.

A key Canadian study released just this week found that 45 percent of patients in Canadian hospitals were malnourished. Further, researchers found that about one-third of hospitalized patients consume less than half of the food they are provided, delaying their recovery time. As the Canadian Malnutrition Task Force says, "Many patients feel unwell and cannot eat. But, patients also do not consume all of their food because: (1) they have difficulty opening packages/unwrapping food; (2) they are interrupted during their meal; (3) are experiencing difficulty reaching their meal trays; and (4) do not find the food appealing." These are all issues that could be easily addressed.

A.S.P.E.N., the American Society for Parenteral and Enteral Nutrition, who sponsors Malnutrition Awareness Week(TM), is calling for a national goal to reduce malnutrition in the U.S. in a new article published in The Joint Commission Journal on Quality and Patient Safety.

"A national goal, combined with a series of specific actions to address disease-related malnutrition, has the potential to improve patient outcomes by reducing readmissions, morbidity, mortality, and costs," said Gordon Jensen, MD, Ph.D., Professor, Head of Nutritional Sciences at The Pennsylvania State University, and one of the article's authors.

Also from a federal policy perspective, we need to renew and strengthen the Older Americans Act. Its nutrition programs, meals and nutrition education which already serve 2.6 million seniors per year and could serve more if expanded, are an effective preventative measure against malnutrition. We need to add malnutrition into the federal Healthy People 2020 goal for nutrition and weight status and treat it as a key indicator of older adult health. We need to address the protein requirements of older adults and need for an increased protein Dietary Reference Intake for this group. We should expand Medicare-covered medical nutrition therapy to include diabetes and other conditions.

The Affordable Care Act with some modifications could play an important role too. A greater emphasis on malnutrition screening and intervention in care transitions grants as well as expanding the definition of essential health benefits to include malnutrition screening and therapy would be two good steps. It is especially important going forward to include nutrition status information, including malnutrition screening and intervention, in electronic health records.

Future legislative initiatives such as the highly touted bipartisan 21st Century Cures legislation should have specific malnutrition provisions in its final version. Similarly the work being led by Senators Warner and Isakson around chronic care management should factor in malnutrition as a key component.

We need to enhance support for the Elder Justice Act as well to deal with rising cases of elder abuse. One of the fastest growing forms of elder abuse is self-neglect which can be caused by the inability to maintain a proper (or any) diet leading to malnutrition or worse.

A number of states including Massachusetts, Louisiana, Florida, Georgia, and Texas have introduced legislation for malnutrition commissions or resolutions designating days or a week for malnutrition awareness. These efforts should be expanded.

Finally, in response to the growing national interest and state and federal initiatives, this week a new coalition was announced: Defeat Malnutrition Today (website, @dftmalnutrition). This bipartisan multidisciplinary coalition will be committed to advancing the idea of nutrition as a key indicator of older adult health in this nation. This will mean working proactively on achievable legislative and regulatory solutions to help defeat malnutrition.

Hidden problems are usually forgotten ones too. We should recognize the real threat that malnutrition poses to our older adult population and take appropriate action to better support healthy aging for Americans.