But just as intravenous feeding and drips are no longer always brought in at the extreme end stage of life, there is something that appears to be a contradiction, this is the risk of malnutrition among the elderly.
A Victorian study of 21 aged care services, published in 2017 in The British Journal of Nutrition found that 68 per cent of the study participants were malnourished or at risk of malnutrition.
The study showed that the amount of meat and dairy foods, important sources of protein, did not meet the recommended levels at that time for the institutionalised elderly.
This finding was confirmed for aged care facilities across Australia in evidence submitted to the Royal Commission into Aged Care Quality and Safety. It’s something our culture didn’t think about much, assuming the frailty caused by malnutrition was part of old age.
Unfortunately, this sometimes went hand in hand with the practice of leaving food in a person’s room and ticking this off as ‘food offered’, when in fact, the tray was left on a bedside table, out of reach.
“There’s a mistaken belief that old people automatically lose weight. But this is not true,”
said Kate Di Prima, a Brisbane Queensland, based dietitian specialising in the elderly.
Ms Di Prima’s professional association, Dietitians Australia, advises the Australian Government on nutritional needs in the elderly and has made recommendations to increase the calorie intake of aged care facility residents.
“In the past we’ve had cooks and chefs working in nursing homes who were completely unaware of the different nutritional needs of the elderly. Then the Royal Commission put the spotlight on it in 2021,” Ms Di Prima said.
“In fact, protein needs increase was we age, not decrease. So, a man of 70 needs 81 grams of net protein per day, while a younger man of 40 only needs 64 grams.”
The consequences are significant and varied, Ms Di Prima explained.
For example, without sufficient protein, muscle deteriorates and no longer protects bone effectively. This means breaking a bone is more likely.
“But it needs to be clear how we manage different elderly residents. Someone who has severe dementia needs to be offered bite sized portions or finger food, so the task of eating isn’t overwhelming to them.
Dental care
“We need to pay attention to dental care in the elderly, so we can ensure people can eat without pain caused by mouth or tooth problems. Letting these continue without intervention is unacceptable,” Ms Di Prima said.
A pilot of new aged care quality standards was introduced in April this year (2023) in preparation for new standards to be introduced on July 1, 2024. But already the Aged Care Quality and Safety Commission, which accredits providers, has increased the number of spot checks done by its staff at aged care facilities and nutrition is one of the items checked.
So today in Australia, goals for ideal weight are monitored and aged care facilities are expected to document weight changes and to screen for malnutrition.
Protection measures
To protect residents, the Commission has a dedicated hotline number you can ring to ask questions about the food being provided for an elderly person in an aged care facility. This number is 1800 844 044.
It’s measures such as these that have led to the anxiety of staff like Sr Pauline’s. But leaders of aged care facilities we spoke to, including Sr Pauline herself, explained that under this reporting system a resident can be defined as receiving end-of-life care and this given as the reason why their weight is dropping.
“Unplanned weight loss as a reportable Mandatory Quality Indicator specifically excludes residents receiving end-of-life care. Information is available on the Department of Health and Aged Care website,” explained Dr Melanie Wroth, Chief Clinical Advisor of the Aged Care Quality and Safety Commission.
But as elderly people manage their lives, discussions need to be had about attitudes towards food and feeding, explaining what happens at the end-of-life, but also talking about diet in the here and now.
A better understanding of why nutrition is important in the elderly, which includes understanding that a person usually stops eating at the end-of-life, will help families to navigate the end-of-life of their elderly family members.
In someone close to dying, but not yet actively dying, there might be several issues to manage. “For example, food needs to continue to be offered so that some of the drugs administered towards the end stage of life can be absorbed properly,” Ms Di Prima said.
Malnutrition in the elderly is Part 2 of the three part series, Feeding at the end-of-life.
Read Part 1: The feeding needs of people at the end-of-life here, and Part 3: The role of supplements, here.