Comprehensive Geriatric Assessment (CGA): Nutrition and hydration

Malnutrition and frailty are strongly linked; people who are malnourished are four times more likely to develop frailty.¹ Frailty has similar diagnostic criteria to both malnutrition and sarcopenia including weight loss, exhaustion, weakness and slowness; therefore treatment of all three conditions should be similar.²

Individuals with frailty should be screened for malnutrition (undernutrition) using a validated tool and consideration given to identifying obesity (overnutrition) and sarcopenia. Although low muscle mass is known to be associated with frailty, direct measurement is difficult. Muscle strength may be a more suitable alternative as it forms part of the diagnostic criteria for frailty.

Key considerations relating to nutrition and hydration should include:

• Appetite

• Fluid intake

• Polypharmacy (consider side effects of medication such as fluid loss by diuretics or weight loss with metformin and other antidiabetic agents)

• Psychological wellbeing

• Ability to carry out activities of daily living (shopping, cooking)

• Socioeconomic background/deprivation

• Sensory loss (smell, eyesight, hearing)

• Oral health

• Gastrointestinal symptoms

• Dysphagia

• Falls risk

• Vitamin D status

Key nutrition and hydration interventions include: 

• Healthy eating guidance specific for older adults which can help prevent frailty and malnutrition (see here)

• Food based guidance for management of malnutrition to support:

  • people living in their own homes (see here)

  • people living in care homes (see here)

• Muscle health guidance (see here)

• Adequate fluid intake for older adults (see here)

• Vitamin D guidance (see here)

Oral nutritional supplements (ONS) are frequently prescribed for older adults with frailty. However, a recent independent systematic review demonstrated that there is limited evidence to support their use in frail older adults³.

Evidence and gaps

Direct comparison of good/appropriate food-based interventions with prescribed products in people with malnutrition, particularly in care homes. The NIHR funded REFRESH trial (nutRition intervEntions For malnouRished oldEr adultS in care Homes) is currently underway.

Nutritional interventions specifically for older adults with frailty from ethnic minorities. The NIHR funded EMPoWER study (Effectiveness of a Multi-modal intervention to Promote independence and WEllbeing among oldeR adults of South Asian heritage: a feasibility study) is currently underway.

There is very limited evidence on the role of food in the management of malnutrition, frailty and sarcopenia but it is important to remember that this does not mean that food is ineffective, it just has not been studied.

There is no validated screening or assessment tool to identify dehydration.

Further reading

• GLIM criteria for the diagnosis of malnutrition – A consensus report from the global clinical nutrition community.⁴

• A Review of Nutritional Requirements of Adults Aged ≥65 Years in the UK.⁵

• Nutrition and frailty: opportunities for prevention and treatment.⁶

• Low-intake dehydration prevalence in non-hospitalised older adults: Systematic review and meta-analysis.⁷

• ESPEN guideline on clinical nutrition and hydration in geriatrics.⁸