By Carol Ireton-Jones, PhD, RDN, LD, CNSC, FASPEN, FAND
I am a registered dietitian, and I know about malnutrition.
So how did I miss it with my mom?
Mom got me interested in nutrition at an early age. She cooked
every day and made me fresh squeezed orange juice every morning. She knew about
the importance of good nutrition and eating well. Since Dad died in 1998, Mom lived
alone and prepared her own meals. Breakfast was often an egg or cheese on toast,
yet I am not sure what she had for lunch and dinner. My family and I saw her at
least weekly, and often we shared a meal. She always ate well when we were
I started going with Mom to her biannual cardiology
appointments about 10 years ago. She always got a thumbs up—her weight never
really changed, and her heart was strong. And she is 96! In 2016, my mom got
pneumonia and was initially treated with oral antibiotics, but she ended up
being hospitalized so she could get IV antibiotics. When she was in the
hospital, she confessed, “I know why I am sick; I haven’t been eating right.”
This is when I first realized she wasn’t really eating at
home. Though she went to the grocery store weekly, she said, “I bought the food…
I didn’t eat it, but I bought it.” Often it was one banana, a few sprigs of
greens, six shrimp, and a six-pack of Milky Way candy bars and Devil Dogs. I
thought she ate well because when she was with us, we saw that she did.
Malnutrition in an older person doesn’t manifest itself as
we would expect. It is a slow decline. And loneliness and eating alone worsen the
decreased nutrient intake. The calories might be ok, but the nutrients they
so much. The obvious signs of malnutrition, like the loss of muscle mass in the
clavicular area, are hard to spot in an older person (especially when they are wearing
a sweater in the summer!). Changes in ambulation are a sign, too, though they
are not easy to define. My mom had a bad knee but could get up from a chair on
Mom’s hospitalization was a wake-up call. I learned a lot
from this “patient” with “starvation-related malnutrition” as defined in the
paper by White, et al., 2012 on malnutrition. It took a long time―almost 3
months—for her to recover her strength and her ability to live alone again. But I
knew things were getting better when Mom said she loved
the food in the hospital and at the rehabilitation unit! She was finally
eating more than breakfast because it was prepared and provided. And she was active,
so she had an appetite.
Here are some thoughts on spotting malnutrition. First,
do a “diet history” with the older person in your life. You don’t need to be a
dietitian to find out what someone has been eating. Don’t ask them what they have
for breakfast—ask them what they eat when they get up in the morning. Mom would
have said coffee and a piece of banana bread or two. Breakfast was always her
best meal. Then ask what they eat next. This is where you might get a little
push back. Check the fridge. Is it empty? Is there anything in there that isn’t
moldy? How about the freezer? If the fridge is empty, or you see a lot of
uneaten food, that might be a clue that they aren’t eating well. (And if you
see outdated food, throw it out!) I know frozen meals and a microwave really
helped my mom. She might not have needed low calorie foods, but smaller meals
work for older people. Third, find a liquid oral nutrition supplement that they
like. This has made a huge difference for my mom. After the hospital, I gave
her a higher calorie protein drink. After 6 months, she asked for less calories!
She has those drinks at night before bed and anytime she doesn’t have or want a
big meal. And finally, try a home delivered meal service or a home chef. We got
a home chef for Mom for a short time, and she loved the smells while the chef prepared
a week’s worth of meals. After the chef left though, she still ate alone. I
think an older person eating alone is the biggest challenge—Mom was always a
great eater when she was with us. Everything is better with family or friends!
My mom finally recovered, and she and I continued to pay
attention to making sure that she ate better. And at 96, she is just now moving
into a retirement community where meals are served, and she eats with other
Nutrition is so important―the nutrients, calories,
flavor, and texture of the food. Having people to eat with is also important. It’s
not about “super foods,” vitamin supplements, or specialized diets. Malnutrition
can be sneaky, but once it is there, it is hard to recover from, especially as
ASPEN has several resources that help identify malnutrition:
a poster entitled, “Ask
About Your Nutrition,” addresses appetite, unplanned weight loss,
amount eaten, feeling tired or weak, and fluid accumulation; “A Guide for
Adults: How to Spot and Talk About Symptoms That Could Mean You’re Malnourished”
includes responses someone might give when asked about their food intake. This information
should be in everyone’s hands—nurses, doctors, dietitians, pharmacists,
caregivers, administrators, and family members. And we need resources—many of
which are available through accessing senior services in your area. Is Meals on
Wheels available or a similar service? Do any of these services offer a
companion to visit while eating? Is there a local senior center that serves
My favorite author and physician on aging, Dr. Tia Powell,
says this about getting older: “Even toward the end, I hope still to have some
joy.” For an older person, a lot of times that joy is found in sharing a meal
with a family member or friend. And that can help prevent malnutrition.
January 2020 Update: Carol's mother passed away peacefully in December, 2019.
Watch a short video from Carol.
Read more patient stories.