1. Limited Access to Resources – Many elderly struggle to obtain nutritious food due to financial issues, mobility limitations, and food insecurity.
2. Chronic Health Conditions – Illnesses like diabetes, gastrointestinal disorders, and dementia affect appetite, digestion, and nutrient absorption.
3. Lack of Nutritional Awareness – Many are unaware of their dietary needs, leading to poor food choices and nutrient deficiencies.
4. Social Isolation – Living alone reduces motivation to eat well, leading to irregular meals and poor nutrition.
5. Inadequate Healthcare Support – Lack of trained professionals and regular assessments results in undiagnosed and untreated malnutrition.

Common symptoms of undernutrition in older adults include:

• Unintentional weight loss – Often due to inadequate food intake or underlying health conditions.

• Muscle weakness and frailty – Leading to reduced mobility, increased risk of falls, impaired activities of daily living and overall wellbeing.

• Poor wound healing and increased susceptibility to infections - Due to weakened immunity and deficiencies in essential nutrients like protein and vitamins.

• Dry, flaky skin and hair loss – Also indicating deficiencies in essential vitamins and minerals.

• Cognitive decline – Including memory loss and difficulty concentrating.

• Depression and mood changes – Often linked to nutritional deficiencies and poor health status.

Nutritional assessment in the elderly involves a combination of dietary evaluation, clinical examination, anthropometric measurements, biochemical markers, and validated screening tools. A multi-method approach ensures accurate identification of malnutrition and guides appropriate interventions to improve health outcomes in them.

Dietary Assessment: which includes 24-hour dietary recall, food frequency questionnaire (FFQ), food diary technique, dietary history and observed food consumption.

Clinical Assessment: a thorough clinical assessment includes a nutritional history and a general physical examination, with particular attention to organs such as hair, mouth, gums, nails, skin, eyes, tongue, tongue, muscles, bones, and thyroid gland. Assessment should also include medical history and screening for chronic diseases that increase energy demands (e.g., HIV/AIDS, cancer, cirrhosis), conditions causing nutrient loss (e.g., diarrhea, malabsorption), and substance use (e.g., alcohol, smoking, and certain medications).

Anthropometric Assessment: body mass index (BMI): WHO classifications include underweight (<18.5), normal (18.5-24.9), overweight (25-29.9), and obese (≥30). However, BMI can be unreliable in older adults due to height loss and muscle mass changes - sarcopenia. 

Other useful anthropometric indices in them include mid-arm circumference, calf circumference, skinfold thickness, and bioelectrical impedance analysis (BIA).

Biochemical Assessment: serum albumin is commonly used but it’s influenced by inflammation, infection, and hydration status. Others include pre-albumin (shorter half-life and not affected by hydration), transferrin (sensitive to early protein-energy malnutrition but affected by iron deficiency, hypoxia, and chronic infections, and retinol-binding protein (reflects rapid nutritional changes but is affected by kidney function and stress, limiting its use in hospitalized patients).

Screening Tools: validated tools for assessing malnutrition in older adults include the malnutrition screening tool (MST), nutritional risk screening (NRS-2002), malnutrition universal screening tool (MUST), mini-nutritional assessment (MNA) tool and the SCALES test (sadness, cholesterol, albumin, loss of weight, eating difficulties, and shopping problems). The MNA is specifically designed for older adults, it includes 18 items and takes <15 minutes to complete, with an accuracy of 98% compared to comprehensive nutritional assessments. The SCALES test is specifically designed for outpatient use. It has been cross validated with MNA but requires blood tests, limiting its practicality.

The treatment of malnutrition in older adults is usually tailored to its underlying causes and severity. A multidisciplinary team including family physicians, geriatricians, dietitians, caregivers, and other healthcare professionals plays a crucial role in managing nutritional problems. The intervention usually prioritizes addressing the root cause while enhancing nutritional status, lasting for at least three months. Patient-centered care is essential, focusing on empowering individuals to maintain proper nutrition and prevent malnutrition. Effective communication, coordination, and training among healthcare providers, caregivers, and community services are vital for successful intervention and monitoring. The MNA tool categorizes older individuals into three groups: normal nutritional status, at risk of malnutrition, and malnourishing. Those with normal nutrition undergo periodic reassessment annually for community dwellers, every three months for institutionalized individuals, and after acute illnesses. Older adults’ at-risk malnutrition but without weight loss require close weight monitoring and reassessment every three months. However, those experiencing weight loss receive oral nutritional supplementation (ONS) of 400 kcal/day alongside further nutritional evaluation. Malnourished individuals require ONS of 400-600 kcal/day, and enteral feeding is considered in severe cases or when oral intake is not possible. Examples of the standard ONS are Ensure Plus (Abbott), Fortisip (Nutricia), Helmix and Boost Plus (Nestlé).8 In addition to these commercial products, local food mixtures that are readily available, such as Tum-brown (roasted corn and soybeans) and Quash pap (maize, millet, or sorghum, sometimes fortified with soybeans, ground nuts, or milk.) can also be utilized. Although these are not standardized meals, their potential as nutrient-dense foods depends on their ingredients and preparation methods.

Preventing malnutrition in the seniors requires a proactive, patient-centered approach that addresses both dietary intake and underlying health conditions. Regular nutritional screening using tools like MNA helps identify individuals at risk, enabling early intervention. Older individuals should receive balanced meals rich in protein, healthy fats, vitamins, and minerals. Locally available nutrient-dense foods such as Quash Pap or Tum-Brown can be beneficial when fortified with additional protein sources like milk, ground nuts, or eggs. Effective prevention also includes promoting adequate hydration, managing chronic illnesses, and ensuring good oral health to facilitate proper food intake. Nutritional education programs can empower caregivers and older individuals to make informed dietary choices. By prioritizing early detection, proper dietary interventions, and coordinated care, the burden of malnutrition among older adults can be significantly reduced, improving their overall quality of life.

Managing malnutrition in older adults requires a holistic and patient-centered approach, especially in cases where psychosocial factors play a significant role. An elderly older adult woman under our care presented with recurrent loss of appetite with features of malnutrition that did not respond well to conventional dietary interventions. Interestingly, her appetite usually improved significantly on Sundays, the day her children and grandchildren used to visit her. This pattern highlighted the profound impact of social interactions and emotional well-being on nutritional status. Recognizing this, we shifted our focus from solely medical and dietary interventions to incorporating psychosocial support as part of her treatment plan. We encouraged her family to increase their visits, arranged for improved family support, and integrated shared mealtimes into her care routine.  

Despite limited resources, this approach yielded remarkable improvements. With consistent family engagement, her appetite and overall nutritional status stabilized, reducing the need for intensive nutritional supplementation. This case emphasizes the importance of addressing social determinants of health when managing malnutrition in older adults. While financial and material resources may be scarce, leveraging family support, emotional well-being, and community-based interventions can be cost-effective strategies to enhance health outcomes. This experience reinforces the need for integrated care models that go beyond medical treatment to include social and emotional support, ensuring sustainable improvements in elderly nutrition.