Malnutrition in Nursing Homes

Malnutrition is associated with many chronic diseases of aging. The term malnutrition refers to both undernutrition and overnutrition. Most often times in the nursing home, it is due to undernutrition.

Federal regulations under The Omnibus Budget Reconciliation Act of 1987 define unacceptable weight loss in a nursing home setting as any weight loss over 5% of total body weight in the past month or over 10% in the past 6 months. Standards of care under Medicare dictate that a nursing home resident maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrates that this is not possible and that a resident receives a therapeutic diet when there is a problem.

Adequate nutrition should always be provided unless a fully competent elder refuses all nutritional support after having been fully informed of the potential consequences and states this in written form with witnesses, or a terminally ill elder has executed a living will or medical directive that precludes tube feedings in the case of terminal illness or impending death.

Nursing homes need to identify those residents that are at risk for malnutrition and implement an appropriate plan of care to ensure proper nutrition. Residents should be assessed on admission, with each change of condition, and at least every three months throughout their stay for risk of malnutrition.

What are some risk factors for malnutrition in the nursing home?

  • Body weight of less than 100 pounds
  • 5% or more weight loss in one month (not intended)
  • 10% or more weight loss in six months (not intended)
  • Presence of pressure sores
  • Nutrition received by tube feeding
  • History of malnutrition
  • Laboratory values indicative of malnutrition or dehydration
  • Mental impairment
  • Depression
  • Limited mobility and needing assistance to eat
  • Poor communication
  • Medication side effects (ex. dry mouth)
  • Teeth problems
  • Restricted diet
  • Poor eating habits and decreased intake at meals
  • Chewing and swallowing problems

How can malnutrition be prevented or corrected in the nursing home?

  • Monitoring monthly weight in all residents and weekly weights for those deemed to be at risk for malnutrition.
  • Performing an assessment that involves the disciplines of nursing, dietary, social services and recreation departments and developing an individualized care plan based on that assessment.
  • Vigilant attention to nutrition and water intake.
  • Catering to food preferences as much as possible
  • Sitting residents with suitable dining partners.
  • Providing enough time for a leisurely, relaxed meal.
  • Preparing foods of appropriate consistency, color, texture, temperature, and presentation.
  • Using herbs and spices to compensate for the loss of the taste of smell sensations and also to avoid using too much salt and sugar.
  • Avoiding packaging that is hard to open.
  • Making sure that seating is comfortable and at the proper height.
  • Correcting any underlying disease or condition, including mouth or hand problems that might interfere with eating or swallowing.
  • Feeding residents who need assistance.
  • Utilizing specialized utensils for those with hand weakness or severe arthritis (available from occupational therapy).
  • Giving between meal dietary supplements in the form of puddings, cereals, and drinks. These should not be given at mealtime due to the risk of decreasing meal intake.

What should I watch for in the dining room of the nursing home during mealtime to see that staff is ensuring proper resident nutrition?

  • Residents are sitting at a comfortable 60-90 degree angle to eat.
  • Nursing staff are seated at eye level and only feeding one resident at a time.
  • The room is at a comfortable temperature.
  • Staff are not talking to other staff during the meal but concentrating on feeding the resident.
  • Staff are not tilting the head and neck of the resident backwards, which can cause choking and aspiration.
  • Residents are being fed slowly through the meal.
  • The fork or spoon is only ½ full to decrease risk of choking.
  • Chewing and swallowing are encouraged for those who need cuing.
  • Supplements are offered to those who leave over 50% of food uneaten.
  • Food is at an appropriate temperature.
  • Uneaten food is removed when the resident is finished eating.
  • Distractions are reduced. There is no TV or loud music in the dining room. Soft soothing music may enhance appetite.
  • Unappealing smells are not present (ex. urine).
  • Most patients are in the dining room to eat (not staying in the room to eat).
  • Mouth care is provided before and after meals.
  • Resident hands are washed before meals.
  • Residents who need their dentures in and glasses on to eat have them.
  • Those who can feed themselves are properly positioned so they can see and reach their food.
  • Food is prepared for those who need it.
  • Finger foods are provided for those who get up and wander during meals.

Tube Feedings

One option in treating malnutrition is tube feedings. Complications of feeding tubes are numerous and include an increased risk of aspiration pneumonia and diarrhea. A person in the advanced stages of dementia who has trouble speaking and walking, as well as eating, is at high risk of complications and will likely not live better or longer when tube fed. On the other hand, a person who has had a stroke and a good chance of rehabilitation may benefit from tube feeding and may recover the ability to swallow.


About Eating, and in Spanish

"Quality dining in the nursing home - Nutrition and the Elderly - Author Abstract".

Nutrition Research Newsletter. . 03 Dec. 2008.

National Citizens' Coalition for Nursing Home Reform

Commonwealth Fund