Normal aging generally is accompanied by modest changes, if any, in appetite, metabolism, intestinal function and absorption of nutrients. Older patients will experience less hunger than younger patients after a period of underfeeding. Various physiological functions that assure appropriate nutrition; ingestion, digestion, assimilation and absorption of nutrients will be affected by the patient’s medical, psychosocial, and functional status. A good bowel program and adequate fluid intake is important (see AMDA’s Dehydration/Fluid Maintenance Guideline) [3]. Inadequate intake of food and fluids may lead to dehydration, constipation, slow gastric emptying, regurgitation, cognitive impairment, aspiration, infection, decubiti, and sepsis.

Every patient admitted to a LTC facility will have some nutritional risk factors such as:

Innumerable drugs can cause anorexia, GI disturbances, and weight loss. These include NSAID’s, opioids, anticholinergics (which reduce salivary and gastric secretions, and GI motility); diabetic drugs such as metformin, digoxin, and cholinesterase inhibitors. Psychotropics particularly TCAs drug can cause diminished cognition, poor oral intake, and constipation. ACE inhibitors and antibiotics may distort normal smell and taste. Anti-acid drugs, especially proton pump inhibitors, may reduce absorption of nutrients such as calcium and vitamin B₁₂. Numerous drugs cause constipation, including analgesics and antihypertensives (especially calcium channel blockers). Opioids and antidiarrheals such as loperamide may decrease peristalsis and potentially result in toxic megacolon. Some drugs cause weight gain, such as the antidiabetic agents and antipsychotics. Polypharmacy can compromise appetite, weight, and nutrition. Recent surgery or trauma may result in immobility, ileus, and constipation. One of the most critical tasks of the admitting clinician is to review and verify the list of medications patients are taking, discontinue unnecessary medications, while ensuring safe transition of patients between health care settings (see AMDA’s Transitions of Care Guideline) [4].

Numerous disease-related factors may cause changes in weight, appetite, swallowing and gastrointestinal function, such as: hyperthyroidism or hypothyroidism and diabetes; neurologic and psychiatric disorders such as Parkinson’s, dementia, or depression; alcohol and other substance abuse; oral/dental problems; numerous GI disorders such as achalasia, malabsorption, peptic ulcers, and irritable or inflammatory bowel disease; and systemic conditions such as scleroderma, CHF, AIDS, cancer, and infection. Physiologic stress due to acute or chronic illness can increase protein and energy requirements and result in weight loss.

In community dwelling elderly the ability to obtain, prepare and eat food may be impeded by psychosocial and functional problems, sensory deficits, limited mobility, or inadequate income. Simply being admitted to a LTC facility where three good meals a day are provided may actually improve nutrition and reverse weight loss.

Several other laboratory parameters can also be monitored in patients who present with weight loss, fatigue, or signs and symptoms of under-nutrition or inadequate hydration. These include a CBC, comprehensive metabolic panel, lipids, and a TSH. Obtaining blood levels of vitamin B₁₂ and 25-Hydroxy-vitamin D should also be considered. Low serum albumin is the single most commonly used indicator of protein malnutrition and is correlated with increased mortality in older persons [11]. These labs should be ordered not only when nutritional concerns are reported but also periodically in patients at risk for poor nutrition.

Screening for dementia and depression is an important component in the management of malnutrition in LTC [12]. Depression and dementia can impact food intake and weight, and may be the most common cause of weight loss. Medications used for these conditions (antidepressants and cholinesterase inhibitors) may further diminish appetite and cause GI upset, leading to further decrease in food intake. Mirtazapine and nortryptyline tend to increase appetite or weight more than other antidepressants, which can be of therapeutic benefit [12]. In one study of older adults depression was one of the most common causes of weight loss (30 %) followed by malignancies [13].

Achieving a healthy weight in LTC patients is controversial. The patient should be counseled and provided meals and nutrition in order to maintain a healthy weight. Obese patients should be put on a healthy diet with perhaps some mild caloric restriction, but dramatic weight loss should not be expected in those who cannot exercise. Giving an elderly resident a too-restrictive diet may decrease the patient’s quality of life and lead to nutritional deficiencies [14]. The optimal weight range for nursing home patients has not been clearly defined but is presumably the same as the general population. A recent article reported that overall mortality rates were lowest with a “normal” BMI (body mass index) in the range of 22.5–25 kg/m² [16]. A longitudinal study of Canadian obese adults indicated that mortality was lowest in moderately overweight individuals (BMI 25–30) [17], indicating that older adults may benefit from extra body weight and protein stores when illness occurs; while those underweight (BMI <20) have an increased risk of illness and mortality. Therefore an optimal weight range for seniors, including LTC residents, appears to be a BMI of about 25 ± 5 (i.e., 20–30).

A more common and concerning problem in the nursing home is underweight. Underweight residents commonly have anorexia, leading to excessive weight loss, malnutrition and frailty, depression, low energy and activity, and associated poor skin integrity. Nursing home patients who lose at least 5 % of their body weight have been reported to be 5–10 more times likely to die [18], but even those who regain weight still have increased mortality. A workup for potentially reversible causes of weight loss should consider GI and other diseases, medication side effects, and depression. If no specific cause is found, one might then diagnose anorexia of aging, terminal stage of dementia or failure to thrive, and the weight loss subsequently determine the weight loss as unavoidable. It is often difficult to determine how aggressive interventions should be given patients’ limited prognosis and decreased quality of life. The facility and family should provide residents with ample enjoyable food that includes a liberalized diet and appropriate supplements.

AMDA’s Clinical Practice Guideline (CPG) on Altered Nutritional Status recommends a process of over 20 steps to evaluate and treat nutritional issues in long term care, beginning with a baseline evaluation of the patient’s nutritional status, weight, height and BMI, and dietary preferences [1]. Risk factors for altered nutritional status including a history of recent weight or appetite change and impaired functional status, as well as any related medical complications such as pressure ulcers should all be documented. The presence of terminal illness, depression, or medications affecting taste or appetite should be noted. The CPG states that treatment should address the underlying issues that have been identified, tailor meals/food to individual preferences and function, limit unnecessary dietary restrictions, and add supplements when necessary. Appetite stimulants should be considered as a last resort and on an individual basis. Tube feedings should only be used in appropriate patients (see “Indications and Usage of Feeding tubes” later in this chapter as well as chapter “Ethical and Legal Issues” for further discussion). The AMDA CPG recommends that practitioners and facilities must continually monitor nutritional status.

The “feed.ME” (Medical Education) Global Study Group has recently published a Nutritional Care Pathway suggesting hospitals and LTC facilities “screen, intervene, and supervene” for the nutritional care of all patients in health care facilities [19].

Recommended fluid intake for the average adult is 3.7 L/day for males and 2.7 L/day for females [2]. This assumes a typical temperate climate and includes total daily consumption of water, all beverages, and the water content derived from solid foods. Those with illness, fever, or experiencing a humid/ high ambient temperature may require additional fluids. Oral intake is preferred; IV therapy is often not available in LTC. An alternative means of hydration is hypodermoclysis (subcutaneous infusion of isotonic fluids) though a short term option [20]. Note that lab abnormalities of electrolytes or renal function do not necessarily indicate “dehydration” [21]. A diagnosis of dehydration may be judged as an indicator of inadequate care and is considered a sentinel event by regulatory agencies.

“Food first”—nutritious food is always preferable to any artificial formula or supplement. In addition to offering and providing sufficient fruits, vegetables, starches, healthy fats, dairy products and fluids, recent position papers have suggested that increased protein intake is generally beneficial in order to maximize muscle and bone health and minimize sarcopenia and osteoporosis [22, 23]. Increasing the recommended daily intake of protein to 1–1.2 g/kg/day was recommended. Two additional studies have reported that a higher protein diet was beneficial in adults over 65 in terms of cancer incidence, function and total mortality [24, 25, 26].

Nutritional supplements such as Ensure are tasty, safe and beneficial for those who can eat and drink but cannot consume sufficient quantities of calories and nutrients via “normal” meals. One can of Ensure contains 250 calories and nutrition equal to ½ of an average modest meal. Various brands of supplements exist with different ingredients/properties, e.g., low glucose, added fiber, or higher fat for pulmonary patients. For details on ingredients and which products are available in your local facility, consult the facility dietary services supervisor or consult dietician. In order to minimize appetite suppression supplements they should be given between meals [1]. An additional option is to provide a nutritional supplement drink rather than water when administering medication—e.g., MedPass 2.0^R (Hormel Health Labs).

Specific vitamin and mineral supplements are generally reserved only for those noted to have specific nutritional deficiencies or medical conditions. However it is reasonable to provide a “senior” multivitamin to all LTC patients. Most women and many men should be encouraged to consume foods rich in calcium and/or receive a calcium supplement to attain a total daily intake of 1200–1500 mg. Due to hypochlorhydria commonly present in the elderly, calcium citrate is preferred due to its better absorption than calcium carbonate.