Malnutrition in healthcare settings usually occurs as some form of protein-energy malnutrition (PEM). Primary PEM is the result of acute or chronic deficiency of both protein and calories. Secondary PEM is due to a disease or medical condition such as cancer or COPD that alters nutrient needs or impairs utilization of nutrients, such as a gastrointestinal disease.

Up to 10% of community-dwelling and homebound older adults, between 23% and 56% of hospitalized older adults, and up to 21% or nursing home older adults are diagnosed with incidence of protein-energy malnutrition. Protein-energy malnutrition with or without catabolic diseases will lead to loss of lean body mass, which can result in weakness, gait and balance disorders, falls and fractures, functional decline, insulin insensitivity and an increase in morbidity and mortality. (1)

Prevalence of malnutrition is especially high among those with Chronic Obstructive Pulmonary Disease (COPD), Cancer stage 4, Chronic Kidney Disease, Congestive Heart Failure, Gastrointestinal disease and HIV/AIDS.

A sample of 311 long-term care residents (> or equal to 65 yrs.) was recruited from 3 long-term care facilities. Using data from the MDS, researchers found that nearly 40% of the residents had a BMI <22, and thus met the BMI criterion for malnutrition risk. (2)

Citing a decade of research, authors of a report on malnutrition and dehydration in long-term care facilities indicate that from 35% to 85% of US long-term care residents are malnourished and 30% to 50% are substandard in body weight. (3)

Malnutrition is associated with a decreased quality of life and functioning, increased hospital stays and hospital admission/readmissions, higher health care costs, and increased mortality/morbidity.

Protein-energy malnutrition (PEM) can be determined by anthropometric measures and laboratory values:

BMI of > or equal to 19 to < 22-considered at risk for malnutrition.

BMI of <19-considered to be malnourished.

Unintentional weight loss of >10% of body weight in the last 6 months or >5% weight loss in the last 3 months.

Weight for height ration-<90% of IBW

Serum ALB-<3.5g/dL (although ALB can be negatively affected by disease and fluid status, not just intakes).


RBP (retinol-binding protein) <3ng/mL

Malnutrition can also occur in the obese resident. A high BMI does not necessarily mean that all is well with laboratory values. Lab review is essential for diagnosis of PEM.

Screening tools are available for identifying protein-energy malnutrition and may be part of a long-term care facility’s Point Click Care program. Some tools include the Malnutrition Screening Tool (MST), Malnutrition Universal Screening Tool (MUST), Nutritional Risk Index (NRI), or Mini Nutritional Assessment (MNA). The Registered Dietitian’s assessment is also an invaluable tool in determining residents at risk for protein-energy malnutrition, when height/weight/current labs values are available.

While increased food and beverage intakes would be an ideal solution for those with PEM, many residents are simply not able to consume much at meals due to various factors. Serving 6 small meals per day, planning between-meal snacks, or making small changes such as serving whole in place of 2% or skim milk at each meal, as a way of increasing protein/calorie sources may be helpful to some. While most Registered Dietitians likely prefer a “food before supplements” regime, nutritional supplements which  are concentrated sources of protein/calories are often quite beneficial for many residents with smaller appetites. Making every bit or sip count is the philosophy. An example is a frozen nutritional treat or “magic cup” provides approximately 300 calories and 9 grams of protein in just 4 ounces of nice, cold ice cream-like product. Prescribing a Med pass 2.0 supplement, given with medications or just between-meals, is also a highly effective means of consuming a concentrated source of calories and protein. Administered by the nursing staff often increases the likelihood that the supplement will be consumed by the resident as well.

In the elderly, food intakes tend to decline with advancing age, especially among the very old and frail elderly living in institutional settings. Older people tend to be less hungry at meals, eat smaller meals, eat more slowly, eat fewer snacks, and feel fuller after meals than their younger counterparts.

Appetite and food intakes are affected by poor dentition, declines in sense of taste and smell, altered gastrointestinal function, age-related changes in hormones and neurotransmitters, and use of prescription and over the counter medications.

With the continually increasing costs of healthcare, there is a relatively easy way to reduce the economic and human costs of malnutrition-screen residents for malnutrition, assess those at risk, and intervene nutritionally where appropriate for those residents who will benefit.

Your Registered Dietitian assesses all residents at admission and critical intervals during a stay, and can be key in improving the nutritional status of your residents and thereby reduce your healthcare costs.



  1. Nutrition Care of the Older Adult 3rd Ed. 2016 AND Dietetics in Health Care Communities Dietetic Practice Group
  2. Malnutrition: A Hidden Cost in Health Care Abbott Labs 2006