Improving the assessment of older adult's nutrition in primary care: recommendations for a proactive, patient-centred and aetiology approach

BACKGROUND The nature of the problem The UK has an ageing population, with the greatest increase in those aged over 85. While most will have long periods of good health, many will live with long- term conditions, and some will become frail requiring continued support in the community or in care and nursing homes. Prevalence of malnutrition in older adults differs significantly, depending on the healthcare setting (figure 1). Causes of malnutrition in older people are multifactorial, some such as vitamin B12 deficiency are age related, and others such as low vitamin D status reflect reduced mobility impacting time spent outdoors. Also, older people are more likely to be prescribed multiple medications may be underhydrated, suffer alterations to taste and swallowing, have reduced access to food, or difficulties in shopping for, and preparing meals. In conditions, such as chronic obstructive pulmonary disease, inflammation- induced catabolism is greater, with reduced weight and increased risk of sarcopenia is prevalent. Patients may also present with metabolic syndrome issues or obesity with sarcopenia. There is overlap between malnutrition, sarcopenia, frailty and functional ability. A systematic review of 178 644 participants shows that unintentional weight loss has a significant impact on mortality regardless of overweight or obesity, and risk is greater with age. We recognise the complexities of the health economics evidence base including the implications of funding and publication bias, the relative lack of studies in primary care and challenges of demonstrating outcomes for a diverse array of non- commercial interventions. The heterogeneity in the evidence base for nutritional interventions is challenging. The Nutrition Education Policy for Health Care Practice initiative of the NNEdPro Global Institute seeks to disseminate evidence informed practice patterns to build more precise nutrition capacity within the healthcare workforce. We propose this biopsychosocial model practice pattern as a pragmatic and ethical approach to improve the nutrition of older adults by earlier identification of malnutrition and initiating relevant actions by any healthcare professional (HCP).