Proven Practice: nutrition in the elderly

Each week the Social Care Institute for Excellence analyses research findings behind specific social work practicesThe evidence base for social care practice. This article puplished in Community Care 14 May 2009 under the headline ‘Nutritional care and older people’

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Food and mealtimes are a high priority for older people and the top priority for older people from black and ethnic minority groups, whose needs are not always met by mainstream services. In one study it was found that food defined the quality of the care home in the eyes of residents. But all older people benefit from the provision of appetising, nutritional meals and the support they need to be able to enjoy them.

More than 10% of older people are affected by malnutrition, at an estimated cost to the UK of £7.3bn a year. Malnutrition can be caused or worsened by conditions relating to old age and malnourished older people admitted to hospital tend to stay in for longer, are at greater risk of complications, and have a higher mortality rate (Age Concern 2006, BBC 2006).

Research suggests there are a number of factors leading to malnutrition among older people in the UK including:

● Ageism, discrimination and abuse have been cited as underpinning poor standards of care for older people.

● lack of knowledge about good nutrition among older people and care workers can contribute to the risk of malnutrition.

● Budgetary and resourcing issues can have a detrimental effect on the nutritional care of older people. Staff shortages, lack of training and low food budgets can all hamper older people’s access to and ability to enjoy good quality meals.

Good nutritional care

Although many older people do receive good quality food and mealtime assistance, there are thought to be as many as 90,000 people receiving home care services that could be at risk of malnutrition. Providing social care staff with only a basic knowledge of nutritional care could help to address this. Good nutritional care is founded on the following:

Dignity. People receiving care should be respected and provided with meals that are appropriate and appetising. Assumptions should not be made about people’s preferences based on their religion or ethnicity.

Screening. Nutritional screening should be a routine part of admission to health and social care services. Improving food intake when necessary should be integral to care planning.

Prioritising mealtimes. Mealtimes should take place in a suitable environment, supported by sufficient staff and not interrupted by other activities.

Training. All staff should receive training on nutritional care appropriate to their role. There should also be focus on communication skills for those working directly with older people to enable them to support people with dementia and communication difficulties.

Accountability. Nutritional care should be recognised as a responsibly at all stages of provision from commissioner to assessor to front-line worker.

Support. Information and advice on nutrition, food and eating should be provided to people using services and their carers.

Managing nutrition

Achieving a high standard of food and mealtime provision involves a number of factors. A Commission for Social Care Inspection bulletin stated: “Care homes that meet the national minimum standards for meals and mealtimes are more likely to have: staff that consult with the older people in their care on their needs; managers who met the training needs of their staff; and sufficient staff numbers to support older people in enjoying their meals.” More specifically the following are key characteristics of a high standard of care provision:

Screening and monitoring

Nutritional screening should be routine on admission to hospital or residential care Screening is a process of identifying people who are already malnourished or who are at risk of becoming so. If any particular concerns are raised in screening the relevant referral should be made, for example to occupational therapy where special utensils may help a person to feed themselves or to speech and language therapy where a person has difficulty swallowing.

Assessments and care plans should cover dietary needs and preferences and any mealtime assistance required and front line staff should refer to these records and review them when necessary.

When necessary, food and fluid intakes should be recorded and the findings acted upon.

Food quality and provision

Food should be appetising. Some people with swallowing difficulties may need to have the texture of their food modified, but not all food needs to be pureed and different foods should not be mixed together. When the texture of the food needs to be altered it should be done with the advice of the speech and language therapist.

Staff should enquire into people’s food preferences rather than making assumptions based on cultural background. If a person is unable to make their preferences clear information should be sought from people who know the older person well. The people who use services should be consulted whenever possible in the development of menus.

Food should be of good quality and, when possible, local, seasonable and sustainable.

Food and fresh water should be available and accessible at all times. Where industrial kitchens are inaccessible, provision should me made for people to make themselves drinks and snacks.


Mealtimes should be a time to focus on eating, they should not be rushed and interruptions, such as distribution of medications, avoided.

Assistance should be discrete and focused on providing support while enabling autonomy. For example, napkins are preferable to bibs and adapted cutlery and finger food should be used, when applicable, to enable people to feed themselves.

Although socialising can be a valuable part of mealtimes, there should be recognition of some people’s desire for privacy when eating and it should be offered to those who have difficulties with eating to avoid lack of dignity.


At mealtimes there should be sufficient staff to provide support to those who need it. If necessary, a system of staggered mealtimes should be introduced. There could also be development or use of existing volunteer schemes to ensure every person is assisted to the extent they require.

Staff should have a nutritional knowledge base appropriate to their role.

Home care staff should have sufficient time and skills to prepare a meal of choice for the person using the service.

Practitioners’ messages

● Food and mealtimes are a key priority for older people and the provision of well-balanced meals and the necessary support to enjoy them shapes their care experience.

● Malnutrition affects more than 10 per cent of older people and as many as 90,000 older people who receive home care service could be at risk of becoming malnourished.

● Malnourished older people tend to stay in hospitals longer and have a higher mortality rate.

● Food and nutrition should be integral to the care experience of older people starting with routine screening for the risk of malnutrition by medical and social services.

● Older people should be provided with appetising food, time to eat it at their own pace and the necessary support and help to do so.

● Staff should consult the older person and, when relevant, family members about cultural and dietary preferences. But staff should not make assumptions.

● Staff should be nutritional awareness and be trained and able to communicate with people who have dementia or communication problems.

Further reading

SCIE At a Glance 03: Nutritional Care and Older People

SCIE Adults’ Services Practice Guide Dignity in Care

 Age Concern England

Research abstracts: nutrition and older people

Author: Age Concern, Title: Hungry to be heard: the scandal of malnourished older people in hospital. Reference: Age Concern 2006. Abstract It is a national scandal that six out of 10 older people are at risk of becoming malnourished, or their situation getting worse, in hospital. Malnourished patients stay in hospital for longer, are three times as likely to develop complications during surgery, and have a higher mortality rate than well-fed patients. Ending the scandal of malnourished older people in hospitals will save lives.

Author: Corley Gianetta, Title: Older people and their needs: a multidisciplinary perspective Reference: London: Whurr, 2000. 221p.,bibliog. Abstract Includes papers on: bereavement; studies in financial gerontology and the health, wealth and happiness of older people; nutrition issues; podiatric problems; nursing older people; grandparenting and the implications of the role for community carers; psychotherapy with older people; reminiscence; psychobiography; occupational therapy; independence and rehabilitation; family care; quality of formal care services for people with dementia; and religion and older people.

Author: Paquet Catherine; et al.;Title: More than just not being alone: the number, nature, and complementarity of meal-time social interactions influence food intake in hospitalized elderly patients. Reference Gerontologist, 48(5), October 2008, pp.603-611. Abstract This study evaluated the social facilitation of elderly patients’ food intake beyond the presence of mealtime companions by assessing various relationships.

Author Magee Helen; Parsons Suzanne; Askham Janet; Title Measuring dignity in care for older people Reference London: Help the Aged, 2008. 86p., bibliog.Abstract This study was carried out to identify indicators of dignity in care for older people. The study involved a literature search, focus group discussions and telephone interviews. The aim was to make recommendations on the best way to measure each of the Help the Aged domains of dignified care: personal hygiene; eating and nutrition; privacy; communication; pain; autonomy; personal care; end-of-life care and social inclusion.

Published in the 14 May 2009 edition of Community Care under the Proven Practice slot with the headline ‘Nutritional care and older people’

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