Addressing Elderly Malnutrition in Hospitals

INTRODUCTION

Overview

The 21st century has seen an increase in the life expectancy of individuals in the contemporary environment. Consequently, the numbers of the elderly (those above 65 years) within the community have been progressively burgeoning. It is well known that aging is associated with an amalgamation of impairments and diseases that are associated with cognitive and physical decline. Additionally, these consequently increase the risk of dietary challenges that contribute to conditions such as malnutrition. Malnutrition is described as “a state of nutrition in which a shortage or excess of protein, energy and other nutrients causes measurable adverse effects on tissue/body function (size, shape and composition) and function and clinical outcome” (Schoncherr et al., 2015, p 193). Malnutrition is both a source and result of ill health. In the UK, at least 3 million individuals are malnourished or face the risk of malnourishment. The nursing profession is labelled as an imperative component within the healthcare system. More specifically, nurses are charged with the duty of protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations regardless of the limited time they may have (American Nurses Association, 2010). However, Marian et al. (2013) asserts that malnutrition in the hospital setting among elderly patients remains largely unrecognised and untreated. The lack of knowledge among nursing in hospital setting is often labelled as a key reason for some of the shortcomings in nutritional practice. Nurses and other hospital staff often give food that contains less or more nutrients than needed to older individuals thus causing further functional impairment in their bodies. Nurses in their practice greatly apply evidence based and theoretical forms of knowledge. This is carried out in partnership with the patients in order to measure, design, instrument, and evaluate clinical outcomes. Moreover, research by National Health Service (2014) emphasizes the use of knowledge in achieving the goals of the nursing practice. In this regard, this paper examines the effectiveness of education among nurses leading multidisciplinary teams and families in managing and preventing malnutrition within the hospital setting. Through a systematic review, the paper methodically searches for several peer-reviewed journal articles from databases and analyses the information they possess to solve the problem at hand. More specifically, the review begins with the definitions of malnutrition, assessment of malnutrition in geriatric care, prevention, and recognition of malnutrition. It then focuses on the role of the knowledge and compliance in the management and treatment of the disease before offering a decisive conclusion on the problem at hand.

Search Strategy

According to Ridley et al. (2012), the initial step of a literature review is searching the literature relevant to the topic. The author recommends the use of systematic approach that is organised and all-encompassing to find the most appropriate literature for inclusion. For this case, the literature search and identification was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The PRISMA guidelines ensured a procedural approach in the identification of sources from the initial process of keyword identification to identification of themes within data.

Keyword Identification

The search process began by identifying the keywords within the research topic. According to PRISMA (2016), the identification of keywords before a literature search is imperative in helping the researcher to maintain the direction of the research. For the topic “The Role of a Nurse in Recognising Malnutrition in Elderly Patients in Hospital,” the keywords identified included “Malnutrtion”, OR “Diet” OR “Nutrition” AND “Older” OR “Elderly” OR “Geriatric” OR “Aging” AND “Nurs*” OR “Caregivers”.

Literature Search

The literature search was then initiated once the keywords were identified. In this case, the search was conducted in online databases as they incorporate the most recent literature, which is accessible in comparison to offline sources such as books. Moreover, errors in the online articles can easily be corrected thus they are more reliable than offline sources. Additionally, Aveyard (2014) state that online databases offer the chance of locating more relevant sources since they offer the possibility of searching through multiple databases for shorter periods of time. In this case, the researcher selected four of the most widely used evidence databases. These included Sciencedirect, CINAHL Plus, MEDLINE and NICE. The researcher also considered the accessibility of the databases from the institutional library. More specifically, Sciencedirect is considered as one of the largest journal databases including millions of articles published by the Elsevier publishers. It includes a wide range of subjects that range from business studies to medical sciences. The second database, known as the Cumulative Index to Nursing and Allied Health Literature (CINAHL), is an online database that features a plethora of scholarly articles in healthcare, nursing, allied health and biomedical sciences. It was included in the search as a relevant source of information in the research. The third database, known as the Medical Literature Analyse and Retrieval System Online (MEDLINE), is a databank providing literature in biomedical information and life sciences. It has a myriad of articles collected from various journals in different fields of healthcare practice. The search was conducted via specific inclusion/exclusion criteria.

Inclusion/Exclusion Criteria

Inclusion/exclusion criteria exist to enable a focused search strategy that ultimately yields data that will provide appropriate answers to the research problem. In this regard, the researcher first ensures that the articles selected were peer-reviewed to ensure that they were reliable and valid. Peer-reviewed sources often have the ability to promote better understanding in subject areas (Aveyard, 2014). The peer-review process also ensures that the articles are acceptable within literature and therefore have quality information in the research subjects. Nevertheless, peer reviewed articles cannot be considered as the golden standard in literature. According to a study by Lee et al. (2013), peer-reviewed sources may be biased where the review process seems to favour authors because of their past record. Even with these limitations, peer-reviewing is still viewed as one of the best methods of appraising evidence. The articles were also be considered in terms of age. Ridley (2012) asserts that the dynamic nature of research in nursing and healthcare has led to an explosion in the number of studies. In this regard, it becomes imperative to consider the most recent research that is relevant to contemporary practices and contains more insight on developing challenges. In this case, the results were limited to a period of 5 years from Jan 1, 2012 to Jan 1, 2017. Furthermore, the selected research articles to include primary qualitative and quantitative studies written in the English language only. The geographical setting of the journal articles was not included as a means of reducing bias in the selection criteria. Boolean Operators, Truncation and other Filters The study utilised several Boolean operators when combining keywords in the databases. These included the use of “AND” to combine search words, and “OR” to specify alternative search terms for the keywords. Additionally, the researcher applied truncation to the keywords to increase the scope of the search results. For instance, the word “Nurse” was truncated to “Nurs*” to include additional terms such as nursing More specifically the whole search query was “Malnutrition” OR “diet*” AND “old*” OR “geriatric” OR “elderly” and “Nurs*”

Outcomes of the Search

The search was carried out with the aforementioned exclusion/inclusion criteria using the search terms “Malnutrition” OR “diet*” AND “older” OR “geriatric” OR “elderly” and “Nurs* AND “Educat*” OR “knowledge “in all text of the article. However, the initial search yielded 990, 680 results in total. In this regard, the results were narrowed down to include keywords appearing only in the title. In Sciencedirect, 9054 articles were identified through a search of the keywords in the title. In CINAHL complete, 12904 articles were identified through the same criteria. The Medline database yielded 6985 articles through an analysis of the keywords in the title. Finally, a search in the NICE database yielded 685 articles. The researcher saw the need to narrow down the identified articles. The articles were sorted by relevance and the first 50 articles were selected for review. They were then analysed and suitable articles with full-text available were downloaded. In the long run, 9 articles were selected from Sciencedirect, 7 articles from CINAHL complete, 5 articles from MEDLINE and 2 from the NICE database. In total, 23 articles were selected from the literature review. The results are represented in table 3 below.

REVIEW OF LITERATURE

This section organises and presents the concepts found in the reviewed studies. It begins with an overview of the concepts of the literature review to outline the context of the literature review before embarking on the literature review itself. Thereafter, it embarks on the review of literature specifically embarking on themes within the topic of interest.

Background to Literature Review

According to the World Health Organisation (WHO) (2016), malnutrition refers to “the deficiencies, excesses or imbalances in an individual’s energy or nutrient intake”. The National Institute for Health and Clinical Excellence (NICE) (2006) defines the same as “a state in which a deficiency of proteins, minerals and vitamins causes significant adverse effects on body composition, functional or clinical outcome”. It is a pervasive international condition that has adversely affected vulnerable groups including the old population. According to the National Health Service (NHS) in England, an estimated 19.6 billion Euros amounting to 15% of the total expenditure on health and social care was associated in with malnutrition in children and adults. The report, compiled by the National Institute for Health Research (NIHR) centre in Southampton (2015), states that the large expenditures occurred primarily from the high costs of hospitalisation as well as the high prevalence of malnutrition in institutional settings. However, the NICE asserts that interventions developed to combat nutrition in malnourished patients save than rather cost money. Malnutrition in adults is now considered as a source of concern in the UK. The National Health Service (NHS) asserts that majority of the expenditure in handling malnutrition is spent adults, rather than children. Additionally, statistics obtained in 2011 by the National Health Service in 2012 indicated a prevalence of malnutrition with age and care setting. More specifically, the report identified that populations 33.6% of those admitted in hospitals with malnutrition were above the age of 65 years. Due to other factors such as the length of stay in the hospital setting, the occurrence is generally considered as higher. In social care, older individuals also lead in terms of prevalence in malnutrition with a percentage of 36% in older individuals in relation to 24% as presented by younger adults. A report by the King’s Fund (2014) attributes the statistics to the success of the advances of modern medicine. According to the organisation, life expectancy among the global population has increased; more specifically, the mortality rate of individuals above 65 years of age decreased from 48% in 1948 to 14% in 2014. Additionally, the Office for National Statistics (2016) reports a doubling in the figures of individuals aged over 85 in the last three decades. This trend is expected to continue into the future, with statistics predicting 1 in every 5 people aged over 65 by 2030. Although aging may be a presentation of the novel advances in medicine, aging populations are present intricate comorbidities, frailty and disability; in fact, the aging population in the Europe is accounting for a significant portion of the primary and secondary care budget. The Health and Social Care Information Centre (2013) and the Department of Health in England (2013) both agree on the general increase in health spending with increasing age. Approaches to mitigate the challenges of aging are complicated by the relative lack of research regarding malnutrition among patients visiting their clinicians. Additionally, NICE reports inconsistencies in data collection practices to yield valuable information regarding topics related to nursing. The NHS also cites difficulties in tracking the rates of occurrence of malnutrition given the diversity of the old population. The incidence of malnutrition inside the hospital settings in the UK present valid concerns for health bodies given that they occur where healthcare professionals are in abundance. With reference to the Francis reports, the role of nurses in ensuring holistic care in their settings was highlighted. Patients were left without proper nutrition in a facility where the practice was seen as “normal culture” (Robinson, 2013). Furthermore, there is a wealth of published research pointing at the cases of malnutrition within the hospital settings. According to the European Nutrition for Health Alliance (ENHA), 40% of patients are malnourished on hospital admission and may continue the course of their treatment with the condition unrealised. Despite increased focus, there still exists a huge literature gap in stipulating the role of various healthcare professionals in mitigating the problem. The nurse, as a ‘clinical scholar’, is required to synthesise and use knowledge to meet the expected outcomes in the healthcare setting. In this regard, the exploration of avenues to define the role of the nurse in mitigating malnutrition is an essential idea.

Assessment of Malnutrition in Older Individuals

The assessment of nutritional status among patients has emerged as an imperative topic within research. Marshall et al. (2016) assert that nutrition screening should be a regular procedure for the identification of patients at risk and the design of proper management approaches that mitigate the negative effects of malnutrition. Additionally, the authors assert that the methods used should be quick to use and have an ease of use amongst various clinicians or patients themselves. Compher (2012) also holds the same view as Marshall et al. (2016) stating that the accurate assessment of nutritional status is important in providing quality care. Schoncherr et al. (2014) hold the view that the routine screening and assessment as well as timely treatment are imperative to avoid dire consequences and complications such as reduced quality of life, pressure ulcers, and increased mortality rates. Timely recognition and identification of the condition is also important to prevent psychological and psychological consequences of malnutrition. Over the years, there has have been various methods of assessing malnutrition in patients. One of the conventional approaches in assessing nutritional status is the body mass index (BMI). It is composed of a ration between an individual’s weight and the square of their height and is a commonly used tool in measuring nutritional status. The body mass index (BMI) is the main parameter connected in the general evaluation of nutritional status and depends on the equation of weight/tallness squared (kg/m2). The subsequent classifications are: underweight (up to 18.5), average/normal (up to 25), overweight (up to 30) and obese (> 30) (Goost et al., 2016). In any case, the extent that nutritional assessment in this method is not conclusive. The significance of arrangement into these classifications has all the doubts of being inappropriate since these numerical qualities permit no conclusions with respect to the sort, cause, or different impacts of the nutritional status. However, more advanced methods of nutritional screening have been developed for the hospital setting. Despite a plethora of assessment methods for patients with malnutrition, only a few methods have proven to be effective to date (Comper, 2012; Marshall, 2016). Most of the methods were mainly created in the 80s where assessment was carried out via arbitrarily grouped assessments that were often unreliable in nature. With time, improved mechanisms which involved rapid determination of status and ease of use were developed One of the methods of conducting these assessments is the Subjective Global Assessment (SGA); it an instrument developed as a means of providing standardised assessment of malnutrition. According to Bigogno et al. (2014), the tool was developed in the late 20th century to assess the nutritional status in patients hospitalised for surgery. It was then validated after a randomised controlled trial and subsequent tests for nutritional screening. It is a self-reported questionnaire that allows patients to incorporate their personal views about their weight loss, dietary intake, functional capacity, and gastrointestinal conditions. Additionally, a test focusing on the amount of subcutaneous fat present is included to include a holistic overview of the patient’s condition. Despite other researchers certifying the tool as the gold standard, there is still a considerable amount of discourse regarding its superiority over other methods of nutritional assessment. However, the scale is not effective in identifying malnutrition in obese and overweight patients.

Goost et al. (2016) conducted an experiment to determine the nutritional status of geriatric trauma patients using different screening procedures. In this regard, the authors tested whether the body mass index (BMI) suggests signs of malnutrition or if there is a correspondence with more precise assessment techniques. In this regard, the authors compiled data from three techniques; the Subjective Global Assessment (SGA), the Nutritional Risk Screening (NRS) and Mini Nutritional Assessment (MNA). In their results, the authors found out that there was correlation between the methods specifically citing the highest correlations occurring between the BMI and SGA as well as the BMI and NRS. However, there was less correlation between the BMI and MNA. From the research, it was inferred that BMI and other tests yielded give vital data. The SGA not just connects well with the BMI, but add to the general picture with discrete data in regards to medicinal history and clinical discoveries. Further approaches, for example, the MNA and the NRS, additionally demonstrate connections and supplement the general picture with individual data. From the analysis of the statements above, there is a consensus on need for a validated tool that allows a holistic understanding of the nutritional status of patients. The lack of agreement and the subjective nature of judgement have acted as hindrances in the development of a holistic tool.

Recognition and Prevention of malnutrition

Malnutrition is viewed as a vital issue in the clinical setting. As the rate of aging individuals in the populace keeps on expanding and on the grounds that individuals' dietary propensities and nutrition behaviours persistently change, giving older individuals proper wholesome care has turned out to be progressively hard (BAPEN, 2016). For community-based elderly individuals, the hazardous effects of malnutrition are considerable. The basic need in the identification of individuals who are conceivably at danger of unhealthiness is the appraisal of their nutritional status. There is an agreement that undernourished individuals are at extensive danger of having ailments, recouping ineffectively from sickness, and encountering low quality of life (Compher & Mehta, 2016; Elia, 2015; Jensen, et al., 2013). Furthermore, the dietary status of older individuals has been proposed as one of the markers in comprehensive geriatric evaluation. As indicated by the International Classification of Diseases (ICD), malnutrition is a subjective judgement. According to Sanz-Paris et al. (2016), the European Society for Clinical Nutrition and Metabolism (ESPEN) rules characterize malnutrition as a continuous shortfall in vitality and additionally supplements as far as a negative balance between consumption and requirement, which contrarily influences dietary status, physiological capacities and wellbeing. In view of the fact that state of malnutrition can be effectively turned around with satisfactory therapy, reasonable measures must be associated with the suitable treatment (Sanz-París, et al., 2016). In this regard, malnutrition is viewed as a general term utilized for various sorts of inadequate dietary consumption, comprising over-indulging and undernourishment, both of which are examined globally, particularly in institutionalised and elderly patients. The subjects frequently experience the ill effects of absence of protein or fat, and in addition, a deficient supply of minerals and vitamins. What's more, patients become dehydrated because of inadequate liquid consumption for diverse reasons can regularly build up to risky levels (Amarya, et al., 2015). In hospitalized patients with malnourishment, a higher rate of complications, a nosocomial contamination, stretched treatment facility costs, higher death rates and longer clinic stays have been accounted for. According to the WHO (2017), the reasons for malnutrition are complex and can incorporate; inadequately adjusted eating routines, lack of appetite, dementia, challenges with gulping and chewing as well as and gastro-intestinal problems. When malnutrition has been analysed, the relevant medicines can be started. Be that as it may, the finding in itself is hazardous. A few tests are accessible to quantitatively, and additionally subjectively, evaluate the danger of malnutrition and to order it into various classifications of malnutrition. Nutrition needs change all through life. Jensen et al. (2013) asserts that for the elderly, these progressions might be identified with the ordinary maturing process, restorative conditions, or way of life. Over the previous decades, the significance of nutrition status in the elderly has progressively been perceived in an assortment of bleak conditions, for example, growth, coronary illness, and dementia. Nutrition is an imperative determinant of wellbeing in elderly patients. Nutritional status appraisal is fundamental for anticipating or keeping up different chronic illnesses, and notwithstanding to heal. As individuals age, different changes happen in the body, which might possibly influence the nourishing status of a person. A typical issue identified with maturing is loss of bone thickness that is a hazard for osteoporosis (Chang, 2016). The loss of lean muscle can prompt increases in muscle to fat ratio ratios (Compher & Mehta, 2016). Muscle loss is seen even in healthy individuals, which infers that metabolic changes happen amid maturing, making it an all inclusive process. It might be more detectable by loss of quality, useful decay, and poor continuance.

Different changes happen all through the digestive framework. There is a reduction in gastric discharge, which can restrict the assimilation of iron and vitamin B12 (Jensen, et al., 2013). The production of saliva diminishes prompting slower peristalsis and slow bowel movements. Hunger and thirst dysregulation additionally happens (Verbrugghe, et al., 2013). Tangible changes influence the craving from numerous points of view. Lack of proper vision makes cooking, and notwithstanding eating, more troublesome (Amarya, et al., 2015). Decreased taste and smell make the delicacies less engaging. These progressions commonly change dietary patterns and diminish supplement accessibility and ingestion, which can prompt nutritional insufficiencies and different medical issues. Malnutrition is both a cause and an outcome of sick health. It can be of different sorts: undernutrition, overnutrition, or particular supplement related deficiencies. Malnutrition in more seasoned patients is frequently underdiagnosed, and subsequently more training in regards to dietary status is required among older patients. Malnutrition in more aged individuals can prompt diverse medical issues, including a feeble immunity, that builds the danger of diseases; poor injury mending; and muscle weaknesses, which can prompt falls and injuries. Also, malnutrition can prompt further lack of engagement in eating or absence of appetite making the issue worse (Chang, 2016). Numerous elderly patients have an increased risk for malnutrition contrasted to other mature populations. It has been assessed that in the vicinity of 2% and 16% of groups in institutional settings suffer from nutritional insufficiencies in protein and calories (Amarya, et al., 2015). If vitamin and mineral inadequacies are incorporated into this gauge, malnutrition in people beyond 65 years old years might exceed 35% (Amarya, et al., 2015). Malnutrition in older persons is related with different wellbeing concerns. As Chang (2016) puts it, prompts a weak immune framework, expanding the danger of infections, poor injury recuperating, and muscle shortcoming, which additionally prompts falls and fractures. The body deteriorates as malnutrition can prompt further lack of engagement in eating or an absence of craving. Older individuals who are genuinely sick and the individuals who have dementia or have shed pounds are particularly powerless against the impacts of poor nutrition (BAPEN, 2016). Although there is no consistently acknowledged meaning of malnutrition in the elderly, some basic pointers incorporate too little nourishment or an eating regimen ailing in supplements. As a rule, however, malnutrition is frequently brought about by a blend of physical, social, and mental components, for instance, wellbeing concerns, confined eating regimens, low salary, lessened social contact, sadness, and liquor addiction (Compher & Mehta, 2016). The number for hospitalized seniors is likewise high. A cautious nourishing appraisal and instruction are important for fruitful mitigation of malnutrition in the elderly, and for the improvement of suitable and complete treatment arranges. Old age causes different changes in body composition, which have critical outcomes on wellbeing and physical capacities. There is a dynamic decline in lean body mass and an rise in body fat. Declined physical activity represents the increased muscle to fat ratio ratios, and this may prompt diminished vitality with aging (Amarya, et al., 2015). These adjustments in body features, incorporating fat distribution, might be related with changes in different physiological capacities that influence digestion, supplement admission, physical movement, and risks for acute diseases. There is additionally an alteration in bone thickness that comes from a reduction in mineral content, which happens with aging (Chang, 2016). Severe osteoporosis may make the bones in the legs bow under the heaviness of the body. This bowing, composed of changes of the spine, makes estimation of stature unreliable in some senior individuals, even in the individuals who can stand unassisted. (Jensen, et al., 2013) Body weight is effectively influenced by short term contextual factors of life, notwithstanding the impacts of intense and constant maladies or undernutrition.

Energy usage of an individual is decreased with the diminishment in physical movement, and this is an essential element adding to a lessened energy expenditure prerequisite in the elderly. However, the vitality cost of ordinary exercises has been accounted for increment with age . According to Amarya et al. (2015), studies directed at elderly individuals demonstrated that up 70% of the elderly aged 60-69 had physical activity in the past month, and this extent was significantly higher in the individuals aged 70-years and above. Another element of maturing that may confine physical action is that elderly individuals are inclined to building up an assortment of progressive and constant infections; obstructions in airways, angina, and joint inflammation are a few illustrations. Physical movement adds to great physical and mental wellbeing at all ages, and dormancy related with trivial diseases in the ageing regularly prompts loss of muscle mass and, from that point, previous physical activity levels may never be recaptured. More specifically, three distinctive instruments of weight reduction in more established individuals have been distinguished (Amarya, et al., 2015). The first is wasting, where an automatic loss of weight is predominant because of poor nutrition, which is be able to be cause illnesses and mental issues creating a generally negative vitality. Secondly, weight loss may occur in the form of cachexia which is an automatic loss of without fat mass (muscle, organ, tissue, skin, and bone) or body cell mass; it is created by catabolism and results in charges in body structure. Weight may also be lost via sarcopenia; which is a decrease in skeletal bulk, is a noteworthy age-related physiological change in matured individuals; lessened physical movement among the elderly has an essential part, since an absence of activity causes muscle ailment and, progressive, muscle loss. Aged patients with unexpected weight reduction are at a developed hazard for disease, wretchedness, and demise. Weight reduction in the ageing because of intentional or automatic causes has been related with mortality. The main sources of automatic weight reduction are gloom (particularly in inhabitants of full time jobs), tumours (lung and gastrointestinal malignancies), cardiovascular damage, and generous gastrointestinal infections (BAPEN, 2016). Albeit lean body mass may diminish in light of typical biological changes related with age, a reduction of more than 4% every year is an autonomous indicator of mortality (Verbrugghe, et al., 2013). A fast weight reduction of more than 5% in a month is viewed as critical and should be assessed quickly by a general practitioner. The simultaneous use of multiple drugs to treat a single ailment can bring about unintended weight reduction, as can psychotropic prescription lessening (i.e., by reducing mental issues, for example, uneasiness) (WHO, 2017). Nonetheless, early recognition, appraisal, and treatment of weight reduction and nutritious insufficiencies may forestall morbidities among the elderly. Impacts of aging on the impression of smell and taste have been researched which may adjust or diminish food intake. This is a typical issue among elderly people who complain of deficiency of both taste and smell. There might be a dynamic loss in the quantity of taste buds per papilla on the tongue (Eschbach, et al., 2016). The rest of the taste buds, which distinguish essentially harsh tastes, demonstrate a relative increment with aging. Impairment of appetite is regularly connected with a decrease in taste and smell, which happens in up to half of elderly people. Improperly fitting dentures may unwittingly change eating designs because of trouble with biting, prompting the admission of a delicate, low-fibre consume less calories without critical new foods grown from the ground (Amarya, et al., 2015). There are some reported gastrointestinal changes in the elderly that can influence their nourishment consumption, for instance, changes in peristaltic movement of the throat, which may bring about a postponement in oesophageal emptying. Widespread nutritional inadequacies are additionally connected with bacterial infection of the intestines. It was found that 17 of 24 malnourished patients had bacterial infection of the small intestines (Amarya, et al., 2015). There was a critical change in the health status of elderly patients after treatment of bacterial infections with antibiotics. Other gastrointestinal changes happen with age and may influence food consumption (Compher & Mehta, 2016). For instance, more noteworthy satisfaction after a meal and a postponement in gastric discharging have been seen in more older individuals.

In summary, a number of symptoms punctuate malnutrition in older individuals. However, the subjective nature of these characteristics requires a combination of proper tools and assessments. All the studies reviewed in the section point to the importance of investihgating the changes associated with age and malnutrition. The generalisation that age is a risk factor for malnutrition is evident.

Nursing Knowledge and Attitudes

One imperative precondition of adherence to International clinical practice Guidelines (ICPGs) on how to handle malnutrition is the availability of satisfactory and adequate information and knowledge towards malnutrition in human health experts. As per Donabedian's prototype, several constructions such as knowledge and demeanours of the staff, can impact activities such as routine screening and resulting intercessions, which affect the results of patients (e.g. pervasiveness or occurrence of an issue) in an establishment (Amarya, et al., 2015). The Council of Europe (2009) guaranteed experts in care homes should be better taught on lack of healthy sustenance, in light of the fact that inadequate learning, restricted interests and negative states of mind toward sustenance are seen as the most widely recognized hindrances to satisfactory practice (BAPEN, 2016). Nurses have to understand that nourishing needs of the aged is confronted with different difficulties, for example, illness, medicinal challenges, movement levels, and biting and gulping issues. In a research conducted by Verbrugghe et al. (2013), inadequate time and staffing is one of the difficulties faced in the healthcare experienced in light of the fact that the customer relies on upon clinicians since a large portion of them live alone and lack companions or family going (Verbrugghe et al. 2013). Additional studies reviewed also demonstrated attendants give more thought to documentation and pharmaceutical administration contrasted with helping elderly with nourishing themselves. Generally, only a few medical attendants comprehend the need to help. However, lacking measures combined with deficient planning lead to giving more thought to the ailing and malnourished elderly. The dependency on care for example, nutrition congruent with the healthcare is known to be one of the dominating components of lack of healthy nutrition and underweight. Hunger stimulants, for example, proper dishes, talks on nutrition and sufficient pain management have been observed to be gainful methods for malnutrition (Compher & Mehta, 2016). Getting the required information about individual dietary needs and taking after the nutritious diets for elderly has also been cited as a good intervention (Eschbach, et al., 2016). In a study by the aforementioned authors, it was labelled a decent intervention since it empowers the patients to nutrition that will enhance his/her general wellbeing. The principle problems in this respect incorporate the patient’s rejection of care or the wellbeing experts’ neglect to look after the patient. Extensive research on the learning and states of mind of nursing staff in nursing homes are relatively uncommon, be that as it may. Bauer et al. (2015) inspected this information utilizing sample sizes in the vicinity of 66 Austrian nursing homes with 1152 participants. Their study aimed to measure the knowledge and attitudes of registered nurses and nurse aides towards malnutrition care in nursing homes. Using a cross sectional design, the Staff Attitudes to Nutritional Nursing Care Geriatric (SANN-G) scale and the validated Knowledge of Malnutrition-Geriatric (KoM-G) questionnaire were utilised to gather data. Their results showed that 60.6% of the respondents gave correct answers. Additionally, the results showed that registered nurses knew considerably more (65.6%) than their nurse aides (57.3%). The research question that was addressed accurately by most of the participants regarded the elements that emphatically influence nutrition. The question that received the most inaccurate answers on the clinicians to treat malnutrition treatment. Less than half of respondents had positive states of mind towards dietary care. RNs showed more encouraging demeanours than their aids. Overall, the review recognized particular information shortages and regions of negative attitudes in nurses and medical helpers.

Karacsony et al. (2015) also performed a research aiming at measuring nursing assistants' knowledge, skills and attitudes in a palliative approach. The research was based on the background information that nursing care assistants form the bulk of the workforce considering older individuals in care establishments. In spite of the fact that reviews have concentrated on their preparation and advancement needs while giving a palliative approach, a substantial and dependable instrument to assess their insight, aptitudes, and states of mind was lacking. In this regard, the authors performed a qualitative analysis of the instruments available and listed their strengths and weaknesses. Their research asserted that the existing instrument in measuring knowledge, skills and attitudes in nurses were relatively useful but were of limited specificity in assessing their aides. Hence the authors recommended the establishment of a method based on psychometric capabilities of the participants. However, the study never came up with a new instrument to measure the skills and knowledge of nurses within the setting. Other studies also demonstrate about the importance of knowledge and attitudes regarding nutrition assessment and care of hospitalised adults. Boaz et al. (2013) utilised a cross-sectional survey investigating nutrition knowledge, approaches, scientific applications, and task rankings using structured questionnaires in a sample consisting of 106 nurses employed at two government hospitals. In their enquiries about the association between attitudes and nutrition knowledge, it was found out that nurses generally perceived nutritional tasks such as feeding patients, food provision, and nutrition assessment as relatively unimportant. In summary, among medicinal services experts, nursing staff are in the best position to give appropriate nutrition along these lines, their insight and dispositions with respect to lack of healthy nutrition, play an essential part in the arrangement of nutritional care in nursing establishments.

Nutrition Education

Education has long be considered as an imperative tool in increasing the awareness of both healthcare personnel and patients on various issues. According to Compher et al. (2016), various parties involved in the management of malnutrition are progressively reaching the consensus that the current competencies of experts are not within the range of catering for the intricate needs of the increasingly aging population. In most cases, the focus on health in many European countries lies on diseases and treatment. Nevertheless, the aged require care and support that is all encompassing to promote their individual autonomies, daily activities, prevent complications and promote the concept of healthy aging. In this regard, education has been a tool utilised to initiate a paradigm shift from conventional to contemporary practices. Oeseburg et al. (2015) carried out a study to determine the essential competencies for the initial education of nursing assistants and care helpers in elderly care. Using a number of several competencies developed and approved by several experts, a Delphi study was done to identify the essential competencies. The authors identified a set of 116 topics of consensus that highlighted the gap in the existing system of education with the required skills in healthcare situations. The skills in the identified set were in accordance with social and medicinal services needs of the elderly like self-sufficiency, daily functionality, healthy aging and prosperity, inclusion of informal care, and collaborative care. The primary milestone was to make an interpretation of the recommendations into instruction for professional development preparing universities for care aides and nursing partners. Past reviews have demonstrated that dietary training programs help medical attendants and experts in enhancing their insight about the nutritional profiles of elderly and start initiatives to help to decrease weight reduction and debilitated mental exercises. Nutritional education programs involve lessons, group discourses, as well as personal tasks. Amid the program, accentuations are driven on established nutritional standards and challenges, recognised appraisal and techniques are energy composition in food, types of foods, as well as individual food timetables. The instruction program objectives are also done in different classes keeping in mind the end goal to evaluate and distinguish the food requirements necessity of the aged. Tappenden et al. (2013) propose that all nurses must possess the ability to perform an evaluation that encompasses nutritional screening to patients, nutritional recommendations for patients, development of meal timetables, documentation of food intake, provision of nutritional supplements, ability to understand and correlate health conditions and nutritional status and ensure the availability of nutritional care resources. Many authors also label teamwork as a vital element in ensuring the transfer of knowledge among staff and ensuring the best outcomes among patients. Schonherr et al. (2015) advocate for the development of synergy between departments to carry out activities that foster the nutritional health of patients. For instance, nurses should work hand in hand in physicians to ensure that age-related maladies to not influence the food intake of the elderly. Psychologists and nurses need to promote the overall wellbeing of the aged by jointly handling emotional problems. Overall, it is the role of the nurse to put the care plan into practice and ensure that they meet the required outcomes.

Management and Treatment

The advancement of health and nutrition needs of elderly can be enhanced when medical caretakers have knowledge that the aging process is a contributing component to increased nutrition requirements. Moreover, the energy needs of elderly can be found by focusing on the distinct physical and mental status regarding social, monetary, social and religious elements. The E.S.P.E.N. Guidelines concentrated for the most part on evidence-based evaluation and proposal of screening activity and nutritional evaluation for elderly at the of risk of malnutrition with thought for age, way of life, and interactions between drugs and nutrients (Sanz-París, et al., 2016). There is a lessening in the energy needs and the lean body mass as aging continues. Metabolic activity is decreased because of the diminishment in the protein mass. Control of the cell work for homeostasis requires the energy that aids in the metabolic activities. A total decrease in the body protein prompts lessened energy needs that influence the functioning of the metabolic mass. Limited physical exercises can be associated with bone and joint illnesses, incessant heart ailments, neurological diseases, poor vision, or fractures because of osteoporosis (Chang, 2016). Chang (2016), via a cross-sectional study, demonstrated that the susceptible elderly can benefit through exercises. He asserted that the strength of muscle can be reconstructed through a continuous physical activity courses; independence can be accomplished by expanding the patients’ beliefs in their practical capacities, and every day practicing can bring about the development of protein, muscle mass maintenance, and calories are likewise diminished. The elderly are often disappointed since they lose their capacity to smell and taste that prompts diminished food intake. Multivitamins which fills in as supplementary eating regimen cater for the nutrient deficit of elderly living at care homes or institutional settings and moderates the human service costs by bringing down heart illnesses and furthermore developing the immune system in the ageing (Eschbach, et al., 2016). Past reviews demonstrate when that the seniors take necessitated calories, insufficiencies related to nutrition are mitigated. The day by day utilization of energy in the elderly is 30 kcal/kg (Jensen, et al., 2013). Starches, for example, grains are an essential of vitality and utilization of complex sugars that have indigestible fibres are very prescribed for old. Liquid intake can likewise be imperilled as consequence of lack of thirst, purposefully limiting because of incontinence, and lacking admission of fluids with nutrition sessions. Thirst is controlled by osmoreceptors locates in the aorta and renal areas (Amarya, et al., 2015). The mandatory liquid intake by elderly is evaluated to be 30 mL/kg body weight, and a lowest possible value of 1500-2000 mL/d (WHO, 2017). Medical nurses must examine the elderly and identify issues identifying with their energy, supplement, and liquid intake to decide any difficulties that requires intervention. Normal difficulties such contamination and fever are also reasons for lack of hydration among nursing home inhabitants. Medical signs are not adequate to identify lack of hydration in elderly in this way the appraisal of every day liquid consumed can be utilized. The evaluation has 3 phases and these are the first stage, 30 mL/kg body weight; the second stage, 1 mL/kcal/energy expended; and the third phase, 100 mL/kg, 50 mL/kg for the following 10 kg, and 25 mL/kg for the rest of the weight (Amarya, et al., 2015). The suggested day by day allowance for protein is 0.8 g/kg body weight for seniors aged 50 years or more (WHO, 2017). Expanded protein prerequisites in elderly can be connected the decline in lean mass and along these lines, the positive nitrogen adjustment can be managed supported. Around 25% of elderly individuals in care homes are idle, which brings about a negative nitrogen equilibrium (a progressive loss of protein tissue) and furthermore the suggested every day level for protein are not met (BAPEN, 2016). Protein deficiency is likely to happen amid acute diseases, surgery, infections, fractures, and also, the immobile elderly. In this regard, need expansions in protein diets to resuscitate and keep up nitrogen levels (Elia, 2015). The scarce dietary protein allowance in elderly can be credited to trouble in biting, cost of nutrients, and absence of learning about dietary fats that are found in foods rich in proteins.

Although the above paragraph may have labelled fat as a risky supplement, it is a fundamental nutrient that produces unsaturated fats and is a transporter for fat dissolvable vitamins, for example, vitamins K, E, D and A. A plethora of studies have been done to investigate the effects of fats in the elderly (Elia, 2015). Fat assumes an imperative part in the etiology of obesity, cardiovascular sickness; tumour growth has been along these lines been discouraged in older individuals. The association between cholesterol and saturated fats has prompted the suggestion to lessen admission to under 10% of consumed calories (BAPEN, 2016). Wellbeing advancement exercise, for example, weight reduction, reduction in sodium intake, nutritional treatment, and lessened liquor intake are encouraged for elderly. Intakes that encompass vegetables, natural products, as well as low fat, high-fibre grains and rich in micronutrients are recommended (Amarya, et al., 2015). Intervention strategies also involve mineral and vitamin supplements. Nurses are advised to institute a caloric admission above 1500 kcal/day to avoid mineral and vitamin deficiencies and furthermore a Calcium consumption identifying with elderly experiences of constant decencies. Decreased abdominal absorption of calcium has association with osteoporosis. The British Nutrition Foundation (2017) likewise promotes the view that those aged 65 or more years ought to partake at least 1500 mg of calcium. Additionally, majority of the older population are confronted with the trouble getting the required measure of vitamin D because of absence of contact with sunlight, or failure of the body to transform the nutrient by the kidney (BAPEN, 2016). As of late, doctors are recommending at least one supplements for elderly. The capacity of calcium and vitamin D are joined and along these lines, the lessening in retention of calcium is because of changes identified with vitamin D levels, utilization of laxatives for bowel blockage, and gastritis. 800IU and 1200 mg of extra vitamin D and calcium individually decrease the danger of fractures in many reviews (Tappenden, et al., 2013). The suggested every day intake of vitamin A is fitting in elderly since Hepatic stores of vitamin A increments with age. The overabundance of vitamin A can bring about inordinate creation of biochemical hence more established biochemical changes that annihilate the liver. Relative to vitamin A, there is an inversion on account of vitamin B on the grounds that the digestion and assimilation diminishes as one matures and pharmaceutical use (WHO, 2017). Low admission of folate, and Vitamins B6 and B12 should also be considered. Research shows that low convergences of any of B vitamins is identified with hyperhomo-cystinemia and it is a hazard for cardiovascular health (BAPEN, 2016). Besides, vitamin E admission is inside the scope of 400 to 800 IU every day and it decreases the rate of non-catastrophic myocardial areas of tissue in elderly with ischemic coronary illness. Research demonstrates that ingesting of folate may bring down blood homocysteine levels, which lessens the susceptibility to coronary ailments (Jensen, et al., 2013). Management of potassium levels forestalls hypokalaemia impacts. Lacking zinc admission delays the healing of wounds, adjusts the usefulness of the immune system, and day fundamental increases the sensitivity to taste.

Overall, several standards regarding the required nutritional intakes of older patients have been listed. It is key to note that although the requirements may be generalised, individual administration plans should be followed to ensure proper and healthy consumption to avoid malnutrition.

Overall, several standards regarding the required nutritional intakes of older patients have been listed. It is key to note that although the requirements may be generalised, individual administration plans should be followed to ensure proper and healthy consumption to avoid malnutrition.

Conclusions

In summary, the study has investigated the association of aging and the susceptibility to nutritional deficiencies. There are complications in definitions of malnutrition in the elderly due to the personal health conditions and biological changes. Some of the reviewed studies have noted that the occurrence of malnutrition with age is inevitable due to the imbalance between food intake and the nutritional needs. Its causes are linked to disease, physiological changes and contextual factors. Nurses, in their roles and responsibilities, are expected to protect, promote, and optimise health and abilities, prevent illness and injury, alleviate suffering through the diagnosis and treatment of human response, and engage in the care of individuals, families, communities, and populations. However, the prevalence of malnutrition among older populations is indicative of shortcomings in their activities in the healthcare setting. Several nutritional assessment techniques are explored. Research reveals that these tools have progressively developed over the century and aim to become holistic but simple for widespread application in healthcare. However, there is still a lack of consensus on the best tool to assess nutrition within older populations. Tools considered should be capable of early detection to identify the risks of malnutrition. A combination of the SGA and BMI was found to be helpful in assessing outcomes of older individuals. Methods of recognising malnutrition and the risk factors have been well-elucidated. Education and proper training of nurses, and their aides, was found out to be an imperative process in ensuring holistic nutritional care in geriatric settings. Knowledge sharing among nurses as well as other professionals was also identified as a critical success factor for interventions aimed at improving the nutritional status of individuals. Nutritional considerations include ensuring proper carbohydrates, fluids, vitamins and minerals. The process was identified as complex since it is involves the making of decisions using subjective data. In this case, strategies aimed at individualised care were best proposed to evaluate the dependency, medications, mental risk, pre-existing and potential conditions, as well as contextual factors. In conclusion, a person's self-care demand cannot be apparent lest it is assessed and it is vital for nurses to utilise reliable and correct methods in the nutritional assessment of the aged.

Recommendations

The study involved a review of recent articles seeking to unveil concepts on how nurses can provide better outcomes in malnourished elderly populations. The sources labelled malnutrition as a globally prevalent condition. The research has the strength of incorporating a large number of articles from various contexts. This ensured that it is inclusive and relevant to the research question. However, some of the studies were in non-UK contexts where healthcare practice was different thus, findings could not be applied to the UK context. Nevertheless, the following recommendations were reached:

There should be additional studies to determine the most effective nutritional assessment tool for nurses to utilise in geriatric care.

Individualised care should be prioritised in geriatric setting to cater for patients’ individual needs.

Nurses and their aides should be enlightened on the importance of nutrition assessment in old individuals and prioritise it as a major clinical issue.

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