Nutritional well-being is an important part of successful aging. Malnutrition and dehydration can lead to a number of serious health problems. A few examples are infections, confusion, and weight loss. Severe dehydration can be fatal. Malnutrition is costly, lowers the quality of nursing home residents’ lives, and is often completely avoidable.

Prevalence of malnutrition in aged care

Whilst recent press reports focussed on comparing aged care food expenditure and prisons is inappropriate, some have seized upon this to deflect attention away from the real tragedy, which is the unacceptable and high prevalence of malnutrition and the way in which accreditation audits fail to pick it up.

Whilst studies have found between 40-70 per cent of aged care residents are malnourished[1], the Aged Care Quality Agency's own data shows that over a five year timeframe which include over 24,000 visits, just 38 homes (0.16 per cent) failed accreditation standard 2.10 Nutrition and Hydration.

Aged Care Quality Agency - *Number of site visits made to RACF's by year:

2012 - 2013 5,689 visits
2013 - 2014 5,313 visits
2014 - 2015 5,152 visits
2015 - 2016 4,251 visits
2016 - 2017 3,964 visits
Total number of visits - 5 year timeframe: 24,369 visits
38 homes failed accreditation standard: 2.10 nutrition & hydration 38

* Site visits include site & review audits, unannounced visits and assessment contacts
Source data from Quality Agency annual reports

The only public reporting of life in nursing homes are pre-announced visits, the majority being three or five-yearly Aged Care Quality Agency reports, which say nothing about health and welfare outcomes of residents, because they are not actually monitored. Rather, these reports say generic, meaningless statements like “the home has systems to ensure there are appropriately skilled and qualified staff to ensure that services to residents are delivered.”   

This explains, in part, why the Quality Agency won’t detect if a resident is, for example, malnourished or dehydrated. The (then) CEO of the Agency admitted as much in response to concerns by a Community Affairs Legislation Committee about malnutrition in aged care homes where they stated “No, we do not measure nutrition levels. We look at the standards which we expect will stop malnutrition actually happening.[2]  

[1] Dietitians Association of Australia (pre budget submission), 2013; Gaskill, D., Black, L.J., Hassall, S., Sanders, F. and Bauer, J. (2008). Malnutrition prevalence and nutrition issues in residential aged care facilities. Australasian Journal of Ageing. 27(4):189-194. & Banks, M., Ash, S., Bauer, J. And Gaskill, D. (2007). Prevalence of malnutrition in adults in Queensland public hospitals and residential aged care facilities. Nutrition & Dietetics 64:172-178.

[2] Community Affairs Legislation Committee (2 Jun 2010) Health and Ageing Portfolio 

Causes of malnutrition and dehydration in nursing homes

Many things contribute to malnutrition and dehydration in nursing home residents. The following list shows factors that may interfere with getting an adequate amount of the vitamins, minerals, protein, calories, and liquids needed to maintain strength and health.

Physical and psychological causes of malnutrition and dehydration in nursing homes can include: illness, especially congestive heart failure, chronic lung diseases, and kidney diseases; adverse drug effects, such as nausea, vomiting, diarrhea, cognitive disturbances, or sleepiness; food and drug interactions, which decrease the ability of the body to absorb vitamins and minerals; depression and loneliness; swallowing disorders; mouth problems, such as tooth loss, dentures that do not fit properly, mouth sores, and mouth pain; and tremors, dementia, or agitation which affect the residents’ ability to feed themselves.

Malnutrition and dehydration in nursing homes can also result from environmental causes, including:

  • inadequate attention from staff for residents who need assistance eating;
  • lack of individualised care;
  • many residents may lose their appetites from a lack of exercise, exposure to fresh air, or sensory or mental stimulation;
  • staff who are uneducated about proper ways to assist residents with eating and drinking, including proper positioning;
  • reliance on liquid supplements instead of making sure residents eat enough food to get the vitamins and minerals they need;
  • special diets or pureed food, which are often unappetizing or regular food that is served cold;
  • cultural differences that occur when the nursing facility does not serve foods that a resident is accustomed to eating; an unpleasant, chaotic dining room environment, which distracts residents and increases agitation;
  • tube feedings not being administered;
  • absence of fresh water within reach at the bedside and failure to open cartons of milk, juice, and supplements that are left out of reach; and
  • not providing oral health care prior to meals.

Identifying the problem

If you suspect that your family member or friend is not getting enough to eat or drink, ask yourself these questions - does the resident:

  • Seem to be losing weight?
  • Have clothes that fit more loosely than usual?
  • Have dry, cracked lips or a pale-looking mouth?
  • Have difficulty speaking due to a dry mouth?
  • Often complain of thirst and ask for water?
  • Urinate infrequently and have dark yellow urine?
  • Have skin that feels dry and warm to the touch?
  • Have a dry, bright red, and furrowed tongue?
  • Complain that their false teeth no longer fit?
  • Have any mouth tenderness, sores or tooth loss?
  • Have thinning hair or hair that is growing sparser?
  • Have wounds that seem to take longer to heal?
  • Appear weak or disoriented?
  • Have skin that is breaking down or seems loose and looks or feels drier than usual?

What Should You Do?

First, determine if:

  • Your family member or friend can feed herself;
  • The resident is allowed to eat their meal when and where they prefer to have it;
  • It takes a long time for them to eat or is rushed through meals;
  • Resident seems to eat more when you are there to assist them in eating;
  • The resident is uninterested in food/has lost their appetite;
  • Resident's can choose from a menu/ foods that they used to eat at home are on the menu;
  • Healthy snacks are readily available to residents;
  • Resident's like the food in the facility and if alternative foods or beverages are offered;
  • Resident's are on a special diet and if it is necessary;
  • Staff routinely monitors resident's weight.

Second, you should share what you found with the staff of the nursing facility. Let them know that you noticed your loved one's clothes are looser than they used to be, that they look smaller sitting in their favorite chair, or any other observations you have made. Make sure to mention any physical symptoms that you found, such as dry skin and cracked lips. Ask the doctor about a blood test to check for nutritional deficiency or dehydration.

Third, ask for a care planning conference right away. The nursing home should have informed you about your loved one’s weight loss. Find out if the staff knows about the resident's loss of weight. Draw up a care plan with the resident and the staff of the nursing facility. It should include what will be on the resident's meal plan, how it will be served, and who will assist the resident at each meal.

  • Ask staff to develop a hydration program to make sure that your relative/friend drinks 1,500 mL (six to seven 8 ounce glasses) each day.
  • Make sure that the resident is provided with glasses and cups that are not too heavy for them to handle.
  • Check to see if straws are available at mealtime and at the bedside.
  • During hot weather, be on the lookout for excessive loss of fluid, and make sure the resident is drinking an adequate amount of fluid. If they perspires heavily, they will need additional fluids.
  • You may want to help by sometimes bringing the resident's favourite foods and juices to the home.

Loss of appetite and weight loss can indicate depression, so be sure that someone on staff will assess your loved one for this illness. If there is no one on staff who can assess for depression, ask for a psychiatric evaluation. Since medications may also interfere with nutritional well-being, ask if the physician or pharmacist can review all of the resident’s medicines for possible interactions.

Many medications cause dryness of the mouth and loss of appetite, which make it difficult to eat. If your relative is on a special diet such as a low salt diet, ask the doctor if she can be on a regular diet. Eating adequately may be more important that restricting salt intake. Finally, if you suspect the resident has any dental or swallowing problems that may interfere with her ability to eat, ask for a dental and dysphasia (difficulty or inability to swallow) exam.

Fourth, monitor your family member or friend to see they get the care they need. You should start to see weight gain and signs of malnutrition and dehydration disappear. Attend the next care planning conference so that you, your loved one, and the staff can evaluate her progress together.

Fifth, give positive feedback to the staff who take the time to make sure that your relative eats and drinks adequately. Work with the staff to develop a program to ensure that she drinks 6-7 glasses of fluid each day. Also, ask them to measure the resident's intake and output as carefully as possible. If the resident is incontinent, ask if they can check the color of their urine to determine if they are getting adequate fluids. The urine should be light yellow in color.


#2 Lynette Rankin 2022-03-18 22:58
October 15th 2021 my Mother died at a RACF in Townsville from dehydration and malnutrition. Prior to September 30th the facility had been on stage 3 lockdown. On September 30th the facility returned to Stage 2. During October I had been phone to tell me my mother was agitated and didn't know how to die, wanting staff to stay with her. Finally on Oct 15th on seeing her it was unbelievable. Her face was red in colour as if over baked and skeleton in appearance, there is no other description and it was more than apparent she was extremely dehydrated and her face looked like a skeleton with her skin pulled taut over her skull.

While sitting with her on Oct 15th her doctor visited. Her Doctor stood by her bed and nodding his head his just said "Yep", and left the room. My mother die around 11pm that night. Frankly I feel that she was euthanized without permission. Why he didn't order an IV infusion previously on earlier visits is beyond comprehension, surely he must have seen her previously during stage 3 lockdown.

How many of our elderly have died from neglect during Covid and lockdowns. I haven't said anything previously to anyone purely from a sense of guilt that I wasn't able to do anything for her and my grief which I still feel deeply , plus my own health hadn't been good during the same period.

I am not the only one independent person from the facility to witness her condition on her death as the funeral service collected her body, prepared it and then transferred her body to the local Medical School at the local University, as she had donated her body to the Medical School. I know it's now nearly five months since her death, I was unable to talk to the family for sometime as I wasn't dealing with my mother's death very well.

I simply feel something must be done to ensure more is done to prevent deaths from dehydration, malnutrition and neglect, needs to stop. Just because it happened during Covid is no excuse. She hadn't received any Covid vaccinations as I refused permission and at no time was I told she had Covid, let alone anyone else in the facility had Covid. In fact there were very few case in our city until Omicron appeared in December. The 24 hours following her death, only one staff members saw me while I packed up my mother's room. Less than 24 hours following her death, it was as though my mother had never existed as there was no other contact from the facility, as if they wanted or needed to distance them from my mother's death, on reflection. Considering my father was a resident from Feb 2007 until May 2011 and my mother was sent there by her Radiation Oncologist Feb 2011. It wasn't as if I had little or no contact with the facility as until the end of June 2021, I was a regular visit into our city was placed in lockdown the begi of July 2021.

Honestly I can't forgive the RACF for the way my mother died but I really don't know what I can find out it.
#1 Geoff 2016-07-05 18:15
A 92yr old resident in Aged Care was admitted into hospital with severe dehydration, Malnutrition a urine infection and sepsis. He is approximately 6 foot and weighs less than 50 kilos. His son has had concerns for his fathers health for quite a while but his POA refuses to believe the home is not caring for their father properly. The medical POA is insisting he returns to the same home. How can I stop her. VCAT. public advocates office, senior rights won't help me because she has POA medical. Should the home have seen the warning signs and diagnosed him before he got so ill??