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.