# Nutrition and Aging Resource Center

# Aging Network’s Role in Identifying Malnutrition and Abuse

## Updated: October 2021

Leading experts have long recognized the negative impact of malnutrition on overall health and wellbeing, especially among older adults. [endnoteRef:2],[endnoteRef:3]  However, insufficient attention has been given to the prevention and treatment of malnutrition. The recent addition of malnutrition to the 2020 Older Americans Act reauthorization legislation (under Sec 102(14)(B) and Sec 330(1)) represents an essential step towards building the capacity of the aging network to identify and address this prevalent and costly condition among seniors.[endnoteRef:4] ,[endnoteRef:5] [2:  Frequency of Malnutrition in Older Adults: A Multinational Perspective Using the Mini Nutritional Assessment.]  [3:  National Blueprint: Achieving Quality Malnutrition Care for Older Adults, 2020 Update.]  [4:  Older Americans Act Reauthorization Act of 2016.]  [5:  Frequency of Malnutrition in Older Adults: A Multinational Perspective Using the Mini Nutritional Assessment.] 

It is important to prevent malnutrition before it occurs. Within the aging network, local senior nutrition providers often act as first responders for their communities. They may be the first to recognize the warning signs of malnutrition among the older adults they serve. 

In some instances, malnutrition may be caused by, or suspected to be caused by, abuse and/or neglect of an older person. In appropriate circumstances, providers should use proper referral channels to ensure the health and wellbeing of older adults who may be malnourished or may be experiencing abuse or neglect.

# Prevalence of Malnutrition

As many as one out of every two older adults is malnourished or at risk of becoming malnourished.[endnoteRef:6] Older adults are at a higher risk for malnutrition because they are more likely to experience physical, cognitive, psychological, or social and economic changes that can impact the foods they can eat and how their bodies use food. Malnutrition is a significant health issue for seniors and can lead to poor outcomes such as chronic illness, muscle loss and frailty, increase in falls, and loss of independence.[endnoteRef:7] [6:  National Blueprint: Achieving Quality Malnutrition Care for Older Adults, 2020 Update.]  [7:  Ibid.] 

# Causes

Malnutrition is caused by too much, too little, or an imbalance of protein, calories, or other nutrients which lead to adverse effects on a person’s body and how it functions. 

Several factors can contribute to malnutrition among older adults including: 

· Disease.

· Neglect.

· Reduced physical and/or cognitive function.

· Hunger and food insecurity.

· Economic barriers.

· Social and mental health, such as social isolation and depression.[endnoteRef:8] [8:  Ibid.] 

In addition, aging and associated changes such as loss of appetite, limited ability to chew or swallow, and taking multiple medications can impact a person’s ability to eat nutritious meals.[endnoteRef:9] [9:  Ibid.] 

# Red Flags

Malnutrition has many warning signs, including unexpected weight loss, loss of appetite, inability to eat or only eat small amounts, feeling weak or tired, and swelling or fluid retention. Validated screening tools can be used by the aging network – even those without nutrition training – to determine whether someone may be suffering from malnutrition.[endnoteRef:10]  [10:  Ibid.] 

# Is Malnutrition a Result of Elder Abuse and Neglect?

Elder abuse is defined as any knowing, intentional, or negligent act by a caregiver or another person that causes harm or serious risk for harm to a vulnerable older adult. [endnoteRef:11] [11:  Subtitle B – Elder Justice Act.] 

Sometimes malnutrition is caused by or associated with abuse or neglect. For example, a paid or family caregiver may intentionally withhold food or deliberately fail to monitor proper nutrient consumption of an older person for whom they are caring. Older adults traumatized by abuse may also lose their appetite or stop eating.

Malnutrition that is the result of abuse or neglect can be challenging to identify. However, it is important to keep in mind that potential signs of abuse or neglect can sometimes suggest other factors that are unrelated to maltreatment. That’s why a careful and skilled evaluation process should be used which involves the individual and respects the individual’s rights to decide how they live.

Some signs that may indicate malnutrition are listed below.[endnoteRef:12]  They can also signal the possibility of abuse or neglect. Providers should consider working with an expert before drawing conclusions or deciding on what actions to take.  [12:  Addressing Malnutrition in Community Living Older Adults:  A Toolkit for Area Agencies on Aging.] 

## Behavioral and Emotional

· Unusual or sudden changes in personality or behavior.

· Depression, agitation, fear, or anxiety.

· Lack of responsiveness, withdrawal from others, or isolation.

## Physical and Environmental

· Weight loss or gain.

· Change in appearance of skin.

· Unexplained injuries.

· Hair or tooth loss.

· Bruising, especially on arms and face.

· Poor sanitation and hygiene.

· Missing or not using medical aids (e.g., eyeglasses, walker, dentures, medications, hearing aid).

· Items piling up in the home (e.g., mail, meal/food packages, other clutter).

# What can you do?

Malnutrition is not just a nutrition issue, but also a health and safety concern that impacts an older adult’s ability to achieve and maintain independence in the community.

## Identify Malnutrition[endnoteRef:13] [13:  Ibid.] 

Your agency or organization can work to identify malnutrition by:

· Using information gathered with the DETERMINE checklist (for example, the DETERMINE Questions Pathway tool[endnoteRef:14]) and consider adding a validated malnutrition screening tool to your organization’s intake process and other service-related assessment processes.[endnoteRef:15],[endnoteRef:16]   [14:  Greater Wisconsin Area Agency on Aging DETERMINE Questions Pathway Checklist.]  [15:  Addressing Malnutrition in Community Living Older Adults:  A Toolkit for Area Agencies on Aging.]  [16:  Position of the Academy of Nutrition and Dietetics: Malnutrition (Undernutrition) Screening Tools for All Adults.] 

· Addressing the root causes by providing appropriate services and referrals.

· Monitoring client progress and the quality of services delivered.

· If abuse or neglect is suspected, implementing agency policy and procedures.

## Identify Abuse or Neglect

If you suspect malnutrition is the result of abuse or neglect, follow the appropriate policy and procedures developed by your agency or organization. Examples of these policy and procedures include:

· Speaking with your immediate supervisor about the situation to determine if additional safety measures need to be put in place. These safety measures may be for the senior and the senior nutrition professional while they are at the home or out in the community.

· In appropriate circumstances, engaging the older adult in a private conversation about how things are going and whether they would like any help to improve the quality of their lives.

· Reviewing rules about what kinds of cases Adult Protective Services (APS) investigates in your state. You may need to contact local APS if your state law requires mandatory reporting for your agency, but you should always consult with your supervisor about how to proceed. Referral to APS, especially without the consent of the older adult, should be considered a last resort if you suspect abuse or neglect.

· Facilitating a meeting with a specialist in elder abuse and neglect to assess concerns and create a plan for action. 

· If the older adult resides in a congregate long-term residential setting, such as an Assisted Living Facility, a group home, or similar living arrangement, consider contacting a Long-Term Care (LTC) Ombudsman to visit with the senior. The LTC Ombudsman exclusively represents the wishes of the resident. They do not investigate on behalf of the state and they do not take any action unless the resident has requested it. 

· Depending on your state, some nutrition professionals may be mandatory reporters. State law defines who are mandatory reporters. They may be licensed or unlicensed human service workers or social service providers, health care professionals, paid or unpaid caretakers, or other professionals in a position of trust who suspect elder abuse has occurred. In some states everyone, regardless of professional status, may be a mandatory reporter. Learn more about mandatory reporter requirements by state.

· Using the Eldercare Locator website or calling 1-800-677-1116 to find APS or the LTC Ombudsman in your community. If a senior is in immediate danger, call 911. Learn more about the signs of elder abuse and reporting abuse.

# Conclusion

Local senior nutrition providers can prevent malnutrition and identify abuse and neglect among the older people they serve with person-centered, culturally sensitive, trauma-informed approaches. They should know the warning signs and understand the policies and procedures of their organization. By addressing malnutrition appropriately, the aging network can promote the health and wellbeing of older adults while ensuring they are allowed to make decisions on how they choose to live.

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