As mentioned in my blog about what I have been doing this week, I will be working on tools and resources to help reduce frailty in older people who have been discharged from hospital, into the community. We talk a lot about malnutrition but we often don’t talk about frailty.
Frailty is (usually) an age related condition which reflects a state of increased vulnerability to adverse health outcomes. This typically means deterioration, sarcopenia (loss of muscle mass and function), weight loss, increased vulnerability and cognitive impairment (1). People with frailty have increased vulnerability combined with decreased resilience against stressors; or put simply, they don’t bounce back as well after illness or upsets. Frail older adults are at increased risk of falls, disability, cognitive decline, hospitalisations, and death. Symptoms include generalised weakness, exhaustion, slow walking speed, poor balance, decreased physical activity, cognitive impairment, and weight loss (2). Age UK says that around 10% of people aged over 65 live with frailty. This figure rises to between 25% and a 50% for those aged over 85.
Risk factors for frailty include: (3)
- Advanced age
- Physical inactivity
- Female sex
- Dietary patterns (malnutrition can contribute to frailty)
- Ethnic background
- Smoking
- Education
- Alcohol consumption
- Low socioeconomic position
- Living alone
- Loneliness
Identifying people in the community who at risk of or with frailty is important. If we can identify these people, we can try to preserve physical function and independence and reduce adverse health outcomes.
Reducing frailty includes reducing the risk factors ; improving physical activity and dietary intake. From a dietetic perspective, of course, we are focussing on dietary quality and patterns. Evidence suggests that dietary interventions are more effective when in combination with exercise training (4).
There are many reasons why elderly people might be at risk of poor dietary patterns These include:
Biological and medical consequences of ageing
Including : diminished sensory properties, reduced thirst, malabsorption, increased metabolism, chewing and/or swallowing problems, chronic disease, dementia, depression, physical disability and medications.
Social features
Including : immobility, social isolation, low income, limited food storage, inadequate cooking skills, gender roles and the passing or a partner and shopping difficulties.
Many older people also tend to eat food of low nutrient density. Most critical nutrients include protein, calcium, iron, zinc, vitamin B12, B1, D, and folate.
It’s a very difficult problem to tackle and can be very frustrating when trying to encourage clients or family members to eat when they have the difficulties as listed or, indeed, no desire to eat. There are, however,, some strategies we can use to help.
Practical Tips for “building up” someone with a reduced appetite
If someone is eating less, it’s important to make sure that what they do eat is of value and is nourishing. It’s a good idea to make sure the diet is balanced and that there is some protein (to maintain muscle) included at each meal, as well as carbohydrate, fat (for calories especially), fruit and vegetables and fluids. Try not to let them fill up on fluids however, if possible, and offer them after a meal or as a between meal snack.
Offer a variety of attractive, tasty, good-smelling meals and snacks. Use garnishes and sauces to enhance appearance. Often elderly people will need more flavour in their meals due to loss of taste sensation.
Ensure meals are of appropriate consistency and that meat and vegetables can be easily chewed.
Offer meals in a relaxed environment. Don’t start rushing around cleaning the house. Sit down and chat and relax with your family member while they eat. Use plain plates & tablecloth for those who are confused and finger food for those having difficulty manipulating cutlery. – e.g. mini quiche, scotch eggs, sandwiches, cut-up fruit, ice cream in cone, mug of nourishing soup.
If caring for someone who is cooking their own meals and where cooking skills are an issue, try to deliver a few meals a week or use one of the “meals on wheels” style delivery organisations. You could also try to do the initial stages of cooking or preparation to make it easier for those who have limited cooking skills or who find it an effort to cook. Microwave meals may also be useful.
Try not to put your family member off the meal by offering too large a plate full of food. Often this can put people off trying even a small amount. Start with a small plate, which can appear more manageable, and build from there. Use guided choice – offer a choice of two or three foods rather than asking “what do you feel like?”.
3 small meals a day plus snacks in between meals is the aim…every bite counts. Make sure food is in eyesight rather than hidden away in cupboards. Put some snack style foods close by where your family member sits to watch television or by the bed.
Don’t stand on ceremony. If the person you are caring for feels like cereal for dinner and eggs and bacon for lunch, then take the opportunity to give them a meal they are sure to eat.
Offer at least 1 pint milk a day to drink. Milk is wonderful for adding protein and calories. Use milk instead of clear drinks where possible. Adding milk powder to milk also increases the protein and calories.
Ditch the restrictive diet. This isn’t the time to worry about cholesterol. Many times I’ve seen elderly people who are not gaining weight as they are too afraid to add high fat and high calorie meals to their menus. This is the time to use full fat products and high energy snacks. If there are any specific medical issue which are of concern, you should get some individualised advice from a Dietitian.
Share and socialise. Sharing meals with other people has been shown to increase intake due to social interaction. See if there are any clubs or groups where your family member can join in.
Build up on meals – quality not quantity. Add calorie and protein boosters to meals. The trick is to look at each meal and think about what you can add to it to increase its quality without making it a huge and off putting meal.
Some examples of what you could try:
- Add cheese to salads, soup, sandwiches and meals.
- Add sour cream, butter and oils to meals, vegetables and potatoes. Mashed potato is excellent for adding cream and butter and cheese to. Crackers, tea cakes and scones should be buttered.
- Add cream, full fat yoghurt, evaporated milk or custard to desserts, fruit and cereals.
- Use milk and creamy based sauces and dressings at meals
The most important thing is to keep a watchful eye over the person you are caring for. Often when we are close to someone, we can be reluctant to push then to eat and can often fail to notice rapid weight loss and reduced intakes. And if you are concerned, of course, try the tips above but always consult your Doctor to rule out all the reasons for weight loss and loss of appetite and your Dietitian for help and support along the way.
1. Lally F, Crome P 2007. ‘Understanding Frailty’. Postgraduate Medical Journal.
2. Allison R 2nd, Assadzandi S, Adelman M (2021). Frailty: Evaluation and Management. Am Fam Physician. 15;103(4):219-226.
3. Z. Feng M, et al. (2017).Risk factors and protective factors associated with incident or increase of frailty among community-dwelling older adults: a systematic review of longitudinal studies
PloS One, 12 (6)
4. Ni Lochlainn M, et al. (2021). Nutrition and Frailty: Opportunities for Prevention and Treatment. Nutrients. 9;13(7):2349.
