Definition

Compared to younger people, older people suffer more from acute and chronic illnesses. With increasing age, the risk of malnutrition also increases, affecting up to 71% of hospitalized older people ¹.

Malnutrition – especially insufficient protein intake – promotes the onset of sarcopenia in older people, which is defined as reduced muscle strength and muscle mass. The associated loss of physical functionality inevitably results in negative consequences, including an increased risk of falls and fractures, higher mortality and a dwindling degree of self-determination, which in turn leads to an increased need for care  ^2-4.

Accordingly, the early detection and treatment of malnutrition and sarcopenia play a central role. To promote the autonomy and quality of life of older people, it is important to consider physical as well as mental, functional and social aspects ⁵. Carefully evaluated and individually adapted nutrition is essential.

Impact on nutritional status

The first changes in body composition can occur as early as mid-30s, such as a decrease in muscle mass and an increase in adipose tissue. These changes usually accelerate in people over 80 years of age and result in an increasing loss of function. The causes are manifold and include hormonal changes, chronic inflammation, and the diminishing anabolic response to amino acids, which is part of the phenomenon known as “anabolic resistance” ⁶. Medication, reduced appetite, dysphagia agy, sensory changes, cognitive impairment and many other factors can further promote weight loss ⁷. Dehydration occurs in up to one-third of frail patients and can lead to serious health consequences. The proportion of obese older people has also increased in recent years and, in addition to the known negative health consequences, carries a high risk of sarcopenic obesity ⁵.

Adequate nutrition and regular physical activity can delay and/or improve the decline in physical function and the negative changes in body composition ⁶.

Nutrient requirements of older persons. Adjustments needed for malnourished persons, physical activity and age. BW = body weight; d = day.

Aims of Nutritional Therapy

• Maintaining/improving nutritional status and body function
• Preventing malnutrition/nutrient deficiencies
• Ensuring adequate protein intake
• Meeting the individual needs of older people

Two common screening instruments are recommended to assess nutritional status: the Nutritional Risk Screening 2002 (NRS 2002) and the Mini Nutritional Assessment (MNA) (Link NutriScreen). These tools assess a person's nutritional status and identify possible risks of malnutrition.

It is essential to quickly recognize and treat potentially reversible conditions that may contribute to malnutrition. The mnemonic “MEALS ON WHEELS” can help remember relevant factors: Medications, Emotional factors (e.g., depression), Alcoholism, Late-life paranoia, Swallowing problems, Oral factors (e.g., poor oral health, tooth loss, dry mouth), Nosocomial infections (hospital infections), Wandering and dementia-related factors, Hyperthyroidism/Hypercalcemia/Hypogonadism (overactive thyroid, elevated calcium levels, low hormone levels), Enteral problems (e.g., gastrointestinal issues), Eating problems, Low-salt/low-cholesterol diets or other restrictive therapeutic diets, Social isolation or Stones (e.g., gallstones, often linked to chronic cholecystitis) ⁸.

Energy and protein requirements should be met through oral nutrition whenever possible. If less than 75% of requirements are achieved through fortified meals, snacks, or sip feeds, enteral nutrition should be initiated within five days. Parenteral nutrition (PN) should be considered for older individuals if oral or enteral intake is impossible for more than three days or remains below 50% of energy needs for over a week.

Oral Nutrition

Oral food intake plays a crucial role in maintaining nutritional status and muscle health in older age. This approach emphasizes the importance of a balanced diet of “natural” foods to meet protein and energy needs. Adjusting to personal preferences, offering snacks, and using high-energy meals are recommended. Both animal and plant proteins should be included in the diet.

Oral nutritional supplements (ONS), such as protein powders, can increase protein intake, especially when consuming sufficient protein through natural foods is difficult. Whey protein isolates, rich in leucine, are particularly effective for addressing malnutrition and sarcopenia ^{9, 10}.

Finally, raising awareness of the importance of a balanced, protein-rich diet in older age is essential for promoting health and well-being.

Practical Tips (if Indicated)

• Start gradually: From age 50, gently adopt new eating and exercise habits to support age-appropriate nutrition and muscle health. This approach helps meet increased protein needs in older adults and prevents muscle loss.
• Follow exercise recommendations: The Federal Office for Sport (FOSPO) provides practical exercise recommendations for people of all ages. These guidelines can help increase physical activity and support muscle health.
• Optimize breakfast: A typical breakfast, such as bread, butter, jam, and coffee, often lacks sufficient protein. Adding protein-rich foods like eggs, cheese, or muesli with quark can naturally increase protein intake.
• Consider protein powders: If it is challenging to obtain enough protein from natural foods, protein powders, particularly whey protein isolates high in leucine, can help stimulate muscle protein synthesis.
• Example snack: A 40 g serving of nuts provides about 10 g of high-quality protein and high fiber. Tree nuts, in particular, offer a balanced omega-6 to omega-3 ratio and are often locally sourced.
• Increase protein for older adults: For individuals aged 65 and older, higher protein intake per meal is recommended to optimally stimulate muscle protein synthesis. Aim for at least 25 g of protein per meal distributed evenly across three main meals ¹¹.
• Adapt to reduced energy requirements: Energy needs decrease by about 25% between ages 25 and 75, but protein and micronutrient requirements remain constant. Focusing on higher nutrient density is crucial in this phase of life.

Parenteral Nutrition (PN)

PN aims to meet nutritional needs and maintain or improve nutritional status. While prospective studies on PN in older patients are lacking, it remains a safe and effective procedure for providing essential nutrients. The choice of nutritional support—whether enteral or parenteral—should be viewed as a medical treatment to improve or maintain the condition and quality of life of the patient. For individuals with malnutrition, enteral and parenteral nutrition should begin early and be gradually increased over three days, considering blood serum levels of phosphate, magnesium, potassium, and thiamine, to prevent refeeding syndrome (Chapter on Refeeding Syndrome) ¹².

End-of-Life Nutrition

In palliative care, where prolonging life is not the priority, comfort feeding is recommended. Patients should be offered the freedom to eat and drink whatever they prefer orally. Avoid pharmacological sedation or physical restraints during feeding, as these can lead to muscle mass loss, cognitive decline, and interfere with the primary goal of comfort.

Individualized assessment and management of nutritional support for older patients, considering their specific clinical conditions, prognoses, and care goals, are essential.

Monitoring

Monitoring nutritional status and therapy is crucial to ensure patients receive appropriate care and to detect potential complications early. Regular evaluations of patients undergoing nutritional therapy are essential.

This includes:

• Anthropometric parameters: Regularly assess weight, height, BMI, and their progression over time. Changes can reflect improvements or deteriorations in nutritional status. Measurements such as mid-upper arm circumference (cutoff: <24 cm) and calf circumference (cutoff: <31 cm) serve as surrogate markers for total body muscle mass. These measurements are particularly valuable for identifying muscle loss, provided there are no edematous changes. In older individuals, calf circumference is also a predictor of falls, malnutrition, frailty, and increased mortality ^{13, 14}.
• Laboratory tests: Blood parameters such as albumin, prealbumin, hemoglobin, and electrolytes are important indicators for monitoring nutritional status and metabolic health.
• Clinical signs: Evaluate signs such as edema, pressure sores or ulcers, pallor, or oral ulcers, as they may signal underlying nutritional issues.
• Food intake: Monitor the quantity and quality of food consumed, including the tolerance of administered nutrition and any signs of digestive discomfort ¹².

Special Considerations

When monitoring patients, it is essential to address individual needs and potential complications, including:

• Contraindications: Be vigilant about contraindications to specific forms of nutrition, substances, allergies, intolerances, or drug interactions.
• Psychosocial factors: Consider the patient’s mental and emotional health, as these can influence adherence to nutritional therapy.
• Patient preferences: Respect individual preferences, as well as religious and cultural considerations, when designing nutritional plans.

Medications/Supplements

The use of medications or dietary supplements should be personalized. Some medications (e.g., antibiotics, chemotherapeutics, corticosteroids, diuretics, antacids, or biguanides) can interfere with nutrient absorption or create specific nutritional requirements that need to be addressed. While protein-based oral nutritional supplements (ONS) can support dietary protein intake, they should only be prescribed when there is evidence of a demonstrated deficiency.