Working with the older adult population requires Clinical Dietitians to understand how to properly diagnose malnutrition. With a rapidly aging population and increasing admissions to hospitals and long term care, knowing the criteria for malnutrition is key.
In order for your facility to be reimbursed for this condition, the dietitian is required to know the ASPEN malnutrition criteria. If your patient checks any 2 of the criteria then they qualify to be diagnosed with malnutrition.
Here I give you a quick and simple criteria check, making the nutrition diagnosis of malnutrition very straight forward. If you aren’t comfortable diagnosing yet, you will be by the end of this article!
What is Malnutrition?
Malnutrition can technically refer to both under and overnutrition, but more often than not, we are referring to undernutrition. For the purpose of this article, I am going to be referencing it in regards to undernutrition.
According to the Academy of Nutrition & Dietetics (2012), malnutrition is,
“… the result of inadequate food or nutrient intake or assimilation; thus, recent intake compared to estimated requirements is a primary criterion defining malnutrition.”
According to the Cleveland Clinic, malnutrition is,
“…an imbalance between the nutrients your body needs to function and the nutrients it gets. You can be malnourished by a lack of overall calories, or you might have protein, vitamin, mineral deficiency.”
In very simple terms though according to the ASPEN research paper, it is any nutrition imbalance.
Malnutrition Rates in Older Adults
It is no surprise that with an aging population we’re starting to see increased rates of malnutrition. According the the Illinois Department on Aging, malnutrition rates are:
- 1 in 2 older adults are at risk of malnutrition or malnourished
- Up to 60% of hospitalized older adults are malnourished
- 44% of long term care residents are malnourished
These statistics, in combination with my over a decade experience working with older adults, should make you as a dietitian be very aware that diagnosing malnutrition is extremely prevalent. It will be likely the single most common nutrition diagnosis you will give.
ASPEN Malnutrition Criteria to Diagnose
The ASPEN malnutrition criteria to diagnose was developed as a consensus among healthcare professionals in 2012. It was a working group that wanted to recognize an international criteria list for diagnosing malnutrition.
The full research paper is available here.
They came up with ‘official’ criteria that we can use that is both evidence based and research confirmed on what malnutrition is.
In order for a dietitian to diagnose a patient with malnutrition, a patient needs to have at least 2 of the following criteria:
- Insufficient energy (caloric) intake
- Weight loss
- Subcutaneous fat loss
- Muscle mass loss
- Fluid accumulation
- Decreased functional strength
Insufficient Energy Intake
This refers to an individual that doesn’t eat or drink enough calories in order to meet their daily estimated energy requirement (EER). Without meeting their EER they will likely experience weight loss, muscle mass loss and fat loss.
When we’re looking at the older adult population, more often than not they have many chronic diseases. Working as a dietitian with older adults for over a decade, I tend to see patients with chronic kidney disease, cancer, cardiovascular disease, among other conditions.
For that reason, we look at the ASPEN malnutrition diagnosis criteria in the context of malnutrition + chronic illnesses. You would be hard pressed to find an older adult without multiple chronic diseases.
Insufficient energy intake in this context means that they are eating less than 75% of their EER for greater than 1 month. This observation can be made through food intake records, or estimations of their energy intake.
By definition if they are eating less than 75% of their intake for an extended period of time, they are either at risk of malnutrition and will become malnourished if not addressed. Nutrition interventions are needed to correct this.
Weight Loss
The clinical definition of weight loss is:
- Greater than 5% in 30 days
- Greater than 7.5% in 3 months
- Greater than 10% in 6 months (180 days)
If a patient has lost any of these amounts of weight in the time period then they are considered moderate or severely malnourished.
I frequently get asked if it’s slightly below 5%, let’s say for example 4.8%, should you round up? My recommendation to clinicians is to use your clinical judgment.
Technically at 4.8% they would not qualify, but some facilities have a policy of rounding up to 5%. That is a decision that needs to be made by each facility and there should be a policy established.
Subcutaneous Fat Loss
Fat loss is more often than not in malnutrition related to insufficient energy intake. As a result, individuals will begin to lose fat and muscle.
Assessing for subcutaneous fat loss can be done through a nutrition focused physical exam (NFPE). If you want a full breakdown on how to perform the NFPE, read The Nutrition Focused Physical Exam Guide here!
Assessing for subcutaneous fat loss requires clinical judgment as there is no ‘standard guide’ on what it looks like. In simplistic terms though you’re looking for areas in a healthy individual that appears to be ‘sunken in’.
Look at areas such as:
- Cheeks
- Temples
- Arms
- Clavicles
- Rib cage
- Back
- Legs
The healthcare professional will indicate whether the subcutaneous fat loss appears mild or severe.
Muscle Mass Loss
Assessing for muscle mass loss is similar to looking at subcutaneous fat loss. It requires a degree of clinical judgment. Knowing how to perform the NFPE is also how you will perform the muscle mass assessment as well.
The dietitian will assess all the areas the fat loss areas, and will dictate whether the muscle mass loss is mild or severe.
Common areas to look at include:
- Arms
- Legs
- Back
- Facial areas
- Hands
Fluid Accumulation
Assessing for fluid accumulation is incredibly important because at times, edema can mask weight loss. When weight loss is missed, this is a huge indicator that someone is at risk of malnutrition or already malnourished.
If the dietitian suspects that weight gain is a ‘false positive’. Meaning that a patient has gained weight but they appear malnourished, it’s important to check for fluid accumulation. Do a chart review and look at their diagnoses and any notes on edema.
In the facilities, nurses or doctors make note if a patient has edema and will give it a ‘grade’ level. I recommend to dietitians when assessing for fluid accumulation, they ensure their documentation is in line with the grade given by nursing.
Older adults with heart failure, renal failure, liver failure and trauma are at highest risk of developing edema. This highlights ensuring that dietitians review a patient’s medical history in their nutrition assessment.
Reduced Hand Grip Strength
Measuring reduced hand grip strength can be done using an official mechanism, but this is not typically done by dietitians. More often than not a physiotherapist or occupational therapist will perform this test.
I recommend to dietitians to get either the PT or OT to perform this test, as there is no formal training that I am aware of for dietitians in this capacity.
The test will reduce in either not applicable or measurably reduced hand grip strength.
Screening for Malnutrition
Now that we know what the criteria is for diagnosing malnutrition, how do we prevent it?
Screening for malnutrition is one of the number one ways to prevent or reverse it. Malnutrition is common, but in most cases it is both preventable and treatable.
Mini Nutritional Assessment (MNA)
The MNA is a widely recognized tool for screening malnutrition in older adults, especially in long-term care and hospital settings. It’s quick to administer and covers both a short screening section and a more detailed assessment if needed.
The MNA evaluates factors like recent weight loss, BMI, mobility, and dietary intake, helping dietitians identify those at risk of malnutrition or already malnourished.
This tool is particularly valuable because it allows for early detection and intervention, which is crucial in preventing further health complications in older adults.
The MNA’s simplicity, combined with its comprehensive approach, makes it an essential part of nutritional care, guiding dietitians in tailoring interventions to improve patient outcomes.
How Often Should You Screen?
Every older adult admitted to a healthcare facility should be screened within the first 24 hours of admission for malnutrition.
If a patient triggers that they may be at risk of malnutrition, they should be referred to a dietitian immediately.
After that most patients are screened quarterly (every 3 months), annually for a full nutrition assessment, or if they are referred to the dietitian.
Malnutrition Prevention
If an individual has been diagnosed with malnutrition, then nutrition interventions must be put in place. The nutrition goals for a patient with malnutrition can include:
- Prevent further weight loss
- Improve food and fluid intake
- Reduce side effects of malnutrition
- Increase weight to within normal body mass index range (BMI 23.0-29.9 in older adults)
The nutrition interventions should target the root cause of malnutrition in order to correct it. For example, if they have insufficient intake, evaluate for a few of these things:
- Teeth issues
- Chewing or swallowing problems
- Appetite changes
- New medication side effects
- Taste changes
- Food preference changes
- Disease progression
- Recent illness
The interventions will vary based on what the issue is. Though I recommend taking a food first approach, sometimes using an oral nutrition supplement can help to improve weight, reduce malnutrition risks, and improve overall health.
I recommend taking a look at the individual patient and adapting the nutrition care plan to what works best for them. Working with person-centered care means that the individual’s wants and needs are met, and work with them to develop what suits them best.
Enjoyed this article? Comment and let me know! Your involvement, support, and sharing helps to spread the word to those who would also benefit!
References:
The Academy of Nutrition & Dietetics (2012) online publication.
Cleveland Clinic (2024), Malnutrition, online publication.
Illinois Department on Aging (2024), Malnutrition, online publication.
ASPEN Working Group Research Paper (2019), online publication.
The Nutrition Focused Physical Exam Free Guide, 2024, LongTermCareRD.com.
Peripheral Edema (2023), Stat Pearls.
Michelle Saari is a Registered Dietitian based in Canada. She has a Master's Degree in Human Nutritional Sciences and is a passionate advocate for spreading easy to understand, reliable, and trustworthy nutrition information. She is currently a full time online entrepreneur with two nutrition focused websites.
