Nutrition and maximising rehab outcomes in older adults

After a major trauma or injury, the importance of nutrition is not usually the first thing most health professionals think about.  

However, in the absence of adequate nutrition, rehab and recovery will be significantly impaired. The protein, vitamins and minerals in food provide the essential ‘building blocks’ needed to repair damage and heal the body. Without these essential ‘building blocks,’ the body simply cannot heal to the fullest extent possible. 

It therefore seems logical that nutritious food should provide the solid foundation upon which other forms of rehab and therapy are built. Sadly, the importance and impact of nutrition continues to be frequently overlooked and rehab outcomes become compromised due to malnutrition and the associated fatigue, muscle loss and impaired immune response that clients experience.

What is malnutrition?

Malnutrition is when a person consumes fewer calories, protein, vitamins and/or minerals than what their body needs over a period of time, which then adversely affects functioning and body composition (e.g. loss of muscle mass and fat). Malnutrition can occur for a few different reasons, including starvation and/or the inflammation associated with chronic disease or an acute injury. 

The initial signs of malnutrition are usually a low body weight and/or unintentional weight loss.  However, someone can also have an inadequate intake of protein, vitamins and minerals, even if they are obese and/or their body weight remains unchanged.  

Many older adults are malnourished even before an illness or injury.  That means adding the nutritional impact of a trauma or injury on top of that, just compounds the problem.

Is malnutrition a problem in older trauma patients?

Malnutrition affects 10 per cent of the general population over aged 65. On admission to hospital, 33.6 per cent of older adults in the UK are malnourished resulting in longer hospital admissions and increased risk of complications. Internationally, malnutrition rates after one week in hospital tend to increase to 45 per cent and then 76 per cent after three weeks in hospital. 

The National Institute for Clinical Excellence recommends that all UK hospital inpatients be screened for malnutrition. However in practice, only 69 per cent of inpatients on medical, surgical, orthopaedic and critical care units in the UK are being screened for malnutrition and of those, only 45 per cent are being referred to a dietitian for further assessment and treatment.  

Consequences of untreated malnutrition: 

• Decreased muscle function (which can reduce mobility and independence);
• Decreased immune function (which leads to higher rates of infection);
• Impaired wound healing;
• Increased length of hospital stay;
• Increased complications, morbidity and mortality;
• Delayed recovery with less favourable outcomes; and
• Impaired quality of life.

Top tips for improving rehabilitation outcomes in older adults:

1. Screen all clients for malnutrition at your initial assessment

Screening tools will consider the person’s current body mass index along with any weight loss in the last 3-6 months.  There are two main screening tools you can use:

• Malnutrition Universal Screening Tool (MUST) – this is the mostly commonly used screening tool in the UK. However, it is a general screening tool for adults and is not specific to older adults.
• Mini-Nutritional Assessment (short-form) – these questions have been specifically designed and validated to screen the elderly for malnutrition.

2. Refer clients “at risk” of malnutrition to a dietitian

Dietitians are uniquely trained to identify the underlying reasons why someone is underweight or losing weight and can liaise with the medical team if required. Appetite, food choices and food intake are all impacted by a multitude of factors including income, mobility, pain, medication, changes to taste and smell, and the ability to shop, cook, eat and drink independently. Correctly identifying the root cause of the problem will lead to more successful outcomes and dietitians can then provide bespoke treatment and education to treat the condition.

3. Ensure all clients over aged 65 years are monitoring their weight at least monthly

Gradual weight changes are difficult to pick up and so regular weight monitoring is the only way to catch malnutrition early. Clients who are bedbound or wheelchair bound are at high risk of malnutrition and have the greatest difficulty getting weighed. Ensure these clients have access to a platform, hoist, wheelchair or bed scale as required. Calf circumference measurements can be used as a surrogate measure to screen for malnutrition, but this measurement will make it impossible to pick up on more subtle weight changes going forward.

To learn more about the ways that nutrition can improve the rehab and recovery of aged 60+ trauma patients, attend the Silver Trauma Conference in London on September 22, 2022. The session by Sheri Taylor, director and specialist rehab dietitian at Specialist Nutrition Rehab, will focus on the impact that ageing and major injury have on nutritional status and body composition and she will discuss practical strategies for improving rehabilitation outcomes in this client group.

• For more information on the Silver Trauma Conference, visit here

Key references:

BAPEN.  (2011).  Malnutrition Universal Screening Tool.  Available at: https://www.bapen.org.uk/pdfs/must/must_full.pdf

BAPEN. (2016).  The cost of malnutrition in England and potential cost savings from nutritional interventions.  Available at: https://www.bapen.org.uk/resources-and-education/publications-and-reports/malnutrition/cost-of-malnutrition-in-england

Dijkink, S et al (2020).  Malnutrition and its effects in severely injured trauma patients.  Eu J Trauma Emerg Surg; 46(5):993-1004.  Available at: 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7593306/#CR22

Lamb, CA et al.  (2009).  Adult malnutrition screening, prevalence and management in a United Kingdom hospital: cross-sectional study.  British Journal of Nutrition, 102(4).  Available at: https://www.cambridge.org/core/journals/british-journal-of-nutrition/article/adult-malnutrition-screening-prevalence-and-management-in-a-united-kingdom-hospital-crosssectional-study/67FABF4E5C147E476A4270228D2B4AAE

Nestle Nutrition Institute. (2009).  Mini Nutritional Assessment.  Available at: https://www.mna-elderly.com/sites/default/files/2021-10/mna-mini-english.pdf