Interdisciplinary Nutritional Management and Care for Older Adults

Front matter

Perspectives in Nursing Management and Care for Older Adults Series Editors: Julie Santy-Tomlinson - Paolo Falaschi - Karen Hertz

Olof G. Geirsdottir Jack J. Bell Editors

Interdisciplinary Nutritional Management and Care for Older Adults

Foreword

When an older person is recovering or rehabilitating following an episode of ill health, injury, or surgery, one of the most important things those caring for them can do is to make sure that the nutritional aspects of their care are prioritised. Wellnourished patients are a sign of good quality care. Lack of enough to eat and drink is both a care quality and a patient-safety issue because of the fundamental importance of food and water to human life and the associated threats to health, wellbeing, and life. Malnourishment and dehydration are strongly linked with functional decline, frailty, sarcopenia, falls and fragility fracture in older people along with many other complications and health challenges including problems with rehabilitation and full recovery. Food and drink brings pleasure, and mealtimes are also social occasions which support social and mental well-being: facets that can be lost during both acute and chronic ill health. Without good nutrition, recovery from health challenges, injury, and surgery is, at best, delayed and, at worst, impossible. Health and social care services are failing those older people whose undernutrition and malnutrition are either not recognised or recognised but inadequately acted upon.

This book is one in a series entitled Perspectives in Nursing Management and Care for Older Adults (https://www.springer.com/series/15860). The series aims to provide a comprehensive guide to nursing management and care for older adults, addressing specific problems in nursing and allied health professions. It provides a unique resource for nurses, enabling them to provide high-quality care for older adults in all care settings. The respective volumes are designed to provide practitioners with highly accessible information on evidence-based management and care for older adults, with a focus on practical guidance and advice. This title is central to that aim. Both the series and this title were conceived by the Fragility Fracture Network (https://www.fragilityfracturenetwork.org/). Consequently, some of the discussion is based in the orthogeriatric setting. Even so, the information provided and learning offered are equally transferrable to other settings in which care is provided to older people.

An overarching theme within this book is the fundamental importance of an interdisciplinary approach to nutritional care. The intended audience for this book is all health professionals working with older people so it will be of use to anyone providing geriatric care in any setting. Even though the book speaks to all health and social care professionals, all of whom have responsibility for food and nutrition, it has greatest significance for the nursing team. This is not because nurses bear vi Foreword greater responsibility for nutrition than other members of the interdisciplinary team, but because in most clinical settings there are usually more nurses than other professionals and nurses spend more time with patients, particularly when they are eating. Nurses are often champions of good nutrition and can help to put nutritional care high on the agenda of the entire team so that full collaboration of every team member can have the greatest benefit and positive impact on patient outcomes. It is of note that much of the research considering the impact of educating health professionals about nutrition is focused on medical practitioners and medical students. In fact, the influence of the nursing team is likely to be much greater because of their close clinical proximity to patients and much more can be done to ensure that they are well informed and educated as well as able to act on that knowledge and understanding through timely appropriate nutritional interventions.

The editors of this book are both nutritionists. They have contributed to the content of the chapters to lend their expertise in nutrition care. They have also used their expertise and networks to develop a global network of authors with the highest level of knowledge and skills to write each chapter. The book is not, however, aimed at nutritionists; it is aimed at those health professionals who need fundamental, rather than specialist, skills in supporting nutrition in older people. The authors, therefore, represent a range of individuals embodying the whole geriatric care team and beyond with a global perspective. This unique approach means that this book can provide a comprehensive approach to the topic area that speaks directly to those most likely to be able to impact on patient care and outcomes.

The structure of the book is organised so that the practitioner can work their way towards enhanced and comprehensive knowledge that they can apply to practice and provide them with thought provoking ideas regarding practice improvement. Each section and chapter provides the practitioner with detailed information to help them to apply knowledge gained to practice. They work both as a whole and independently so that the reader can step in and out of the chapters as they are able and feel the need.

There are two parts. Part I: Nutritional Care in Geriatrics provides an incremental and comprehensive approach to the fundamental knowledge needed by all members of the interdisciplinary team for excellence in nutritional care. The chapters in this part begin by outlining the nature of nutrition care in geriatric settings and the nutrition requirements of older people receiving geriatric care. This is followed by consideration of the pillars of nutritional care: assessment, diagnosis, treatment, and prevention of malnutrition. The role of the nurse is considered from the perspective of how effective nutritional care contributes to excellence in nursing care. Hydration is an important fundamental aspect of care that is linked to nutrition, so this is considered in a specific chapter. Two chapters, 7 and 8, consider how ageing, malnutrition, sarcopenia, functional decline, bone health, and fragility fractures need to be considered in the fundamental care of the orthogeriatric patient. The importance of patient involvement in, and motivation towards, nutritional care is considered with attention to the psychological barriers that prevent patients from engaging in their care. Leading clinical/practice development and change with a

Foreword vii view to improving, spreading, and sustaining good practice in nutritional care is discussed, along with approaches to the education of the interdisciplinary team.

Part II: Special Topics in Geriatric Nutrition considers specific topics that lead forward from the fundamental topics considered in Part I. These include an exploration of specialist versus generalist nutritional care for older people to support practitioners in understanding their own roles as part of an interdisciplinary approach. The impact of physical activity, exercise, and physical rehabilitation is linked to the need for good nutrition. The fundamental importance of nutrition in pressure ulcer prevention and management is outlined. The topics of obesity, body composition, and BMI are considered to enable the practitioner to incorporate thinking about these in their practice. An overview of the fundamentals of nutritional physiology is included to help practitioners to consider the scientific basis of their assessment and interventions. Attention is given to nutrition in oropharyngeal dysphagia, delirium, drug-food and food-drug interaction and issues relating to food and water at the end of life.

Getting nutritional care right is both fundamental and complex. No member of the team can do this alone but, equally, they cannot delegate it to others as this would be to deny what care is. The undoubted experts in nutritional care are nutrition practitioners/dieticians and those whose training and education enable them to use extensive evidence-based knowledge to inform and guide assessment, diagnosis, and interventions to support the health and well-being of humans through food and nutrition at both individual and population levels. However, there are too few of these experts (and in some localities there are none) to provide this service to every patient at risk of or diagnosed with malnutrition. This means that the rest of the interdisciplinary team need to work together to ensure nutritional care is effective despite any resource issues.

Providing nutrition care is not a job to be delegated to others. Every health and social care professional has a collaborative role to play. To do this everyone needs to be well educated and skilled in making assessments of nutritional status and planning and delivering nutritional care as well as seeking support from other members of the team where needed. This book is designed to enable such practitioners to do just that. Its chapters are a blueprint for learning and extended knowledge about why and how to deliver the nutritional care needed. It should be an essential read, therefore, for all health professionals providing treatment and care to older people with health challenges and following injury and surgery.

Julie Santy-Tomlinson

Orthopaedic Nursing

Odense University Hospitals/University of Southern Denmark Odense, Denmark

juliesanty @tomlinson15.karoo.co.uk viii

Foreword

Paolo Falaschi

Sant’ Andrea Hospital

Sapienza University of Rome,

Rome, Italy

paolo.falaschi @fondazione.uniromal.it

Karen Hertz

University Hospitals of North Midlands Royal Stoke University Hospital, Stoke-on-Trent, Staffordshire, UK karen.hertz @uhns.nhs.uk

Acknowledgements

The development of this book, led by the Frailty Fracture Network, aims to provide a resource for guidance on the interdisciplinary nutritional management and care for older adults, incorporating an evidence-based practical guide for nurses. The editors are very grateful to all those who have contributed in many different ways to this work. Recognition is given in advance to older adult and teams that must work together to tailor multidisciplinary nutritional management and care opportunities and improvements to local settings. FFN and the editors also thank Springer for agreeing to make the English version available on the Internet for open access, and acknowledge Nutricia for an unrestricted/unconditional educational grant supporting open access.

Contents

PartI Nutritional Care in Geriatrics

Ólöf G. Geirsdóttir, Karen Hertz, Julie Santy-Tomlinson, Antony Johansen, and Jack J. Bell

Anne Marie Beck and Mette Holst

Part II: Special Topics in Geriatric Nutrition

Editorial: Specialised Versus Supportive Nutritional Care in Ageing: A Conundrum

Multidisciplinary Nutrition Care: Benefitting Patients

Heather Keller, Susan Slaughter, Leah Gramlich,

Ashwini Namasivayam-MacDonald, and Jack J. Bell

Camila Astolphi Lima, Renato Barbosa dos Santos, and Monica Rodrigues Perracini

Donna Hickling, Tracy Nowicki, and Julie Santy-Tomlinson

Alfons Ramel and Sari Stenholm

Saverio Cinti

Lina Spirgienė, Rebecca Lindhe, and Gytė Damulevičienė

Alison Mudge, Adrienne Young, Margaret Cahill, Elise Treleaven, and Lina Spirgiené

Björn Vidar Aðalbjörnsson and Alfons Ramel

Stefano Eleuteri, Arianna Caruso, and Ranjeev C. Pulle

Part |

Nutritional Care in Geriatrics

Ólöf G. Geirsdóttir, Karen Hertz, Julie Santy-Tomlinson, Antony Johansen, and Jack J. Bell

Engaging older adults, and all those who care for them, is pivotal to providing high-value nutrition care for older adults. Nurses and other interdisciplinary team members are essential to this process. The aim of this chapter is to provide an overview of the rationale and evidence for interdisciplinary and systematised nutrition care as an effective nutrition care approach for older adults with or at risk of malnutrition. This chapter also serves as a guide to detailed chapters

Ó. G. Geirsdóttir (&)

Faculty of Food Science and Nutrition, School of Health Science, University of Iceland, Reykjavík, Iceland

e-mail: ogg@hi.is

K. Hertz Royal Stoke University Hospital, Stoke-on-Trent, UK e-mail: karen.hertz @uhns.nhs.uk

J. Santy-Tomlinson

Orthopaedic Nursing, Odense University Hospitals/University of Southern Denmark, Odense, Denmark

e-mail: juliesanty @tomlinson15.karoo.co.uk

A. Johansen Trauma Unit, University Hospital of Wales, Cardiff, UK

National Hip Fracture Database, Royal College of Physicians, London, UK e-mail: antony.johansen @ wales.nhs.uk

J. J. Bell Allied Health, The Prince Charles Hospital, Chermside, Queensland, Australia

School of Human Movement and Nutrition Sciences, The University of Queensland, St Lucia, QLD, Australia e-mail: jack.bell @health.qld.gov.au

© The Author(s) 2021 3 Ó. G. Geirsdóttir, J. J. Bell (eds.), Interdisciplinary Nutritional Management and

Care for Older Adults, Perspectives in Nursing Management and Care for Older across this book to provide focal points on different aspects of nutrition care that should be considered across primary prevention, acute care, rehabilitation, secondary prevention and community settings (Dreinhöfer et al., Injury 49(8):1393-1397, 2018).

Keywords Fragility fracture - Malnutrition - Nutritional assessment - Nutrition care - Older Hip fracture - Sarcopenia - Nutrition care e Recognise the complexities of nutrition care for old people.

e Explain the rationale and benefit of shifting towards integrated, transdisciplinary nutrition care across healthcare and community settings.

e Apply key questions that will support timely, efficient and effective nutrition care for older persons across broad populations, conditions and settings.

1.1 Defining Malnutrition

Malnutrition broadly refers to deficiencies, excesses or imbalances in a person’s intake of energy and/or nutrients. Undernutrition includes energy or macronutrient deficiencies (protein-energy malnutrition) and micronutrient deficiencies or insufficiencies, while overnutrition is routinely associated with overweight, obesity and diet-related noncommunicable diseases [1, 2]. This book will present a focus on malnutrition as undernutrition.

There is no definitive or ‘gold standard’ screening or diagnostic criteria for malnutrition [3]. Despite the availability of several validated nutritional assessments, malnutrition is often under- or misdiagnosed, overlooked and undervalued in multimorbid older adults, such as those with a fragility hip fracture [4—7].

Malnutrition diagnosis requires a thorough assessment and single-point diagnostic measures are unreliable. For example, malnutrition may be recognised in a chronically malnourished patient with normal albumin levels, but it can also be present in an acutely unwell older adult despite a high body mass index (BMI) of 50 kg/m? [4]. Conversely, an older adult with reduced handgrip strength resulting from motor-neurone disease should not immediately be considered malnourished without further investigation.

Muscle strength and function diminish as part of the normal ageing process, so a centenarian presenting with limited muscle reserves should not automatically be given a diagnosis of malnutrition, until it has been established whether loss of muscle mass, strength and function is in part attributable to malnutrition, for example, related to anorexia of ageing.

1.2 Nutrition Care in Older Adults: A Complex and Necessary Challenge

Malnutrition in older people is increasing in prevalence as the population ages [2, 8-10]. The prevalence of undernutrition in older people living in the community is about one in five [11—13]. Within clinical settings, malnutrition prevalence rates routinely approach half of older adults, although prevalence estimates vary substantially depending on the population, the healthcare setting and methods used for assessment [14-18].

Poor nutritional status is well established as a negative prognostic indicator among older adults, leading to functional decline, lower quality of life and increases in complications, morbidity and mortality, lengths of stay, unplanned readmissions, institutionalisation and costs [19-25]. It is worth noting that malnutrition can more than double the risk of dying for older adults [26, 27].

A practical case example is an older community-dwelling person admitted with fragility hip fracture. Although the surgical intervention and fracture union may have been successful, extended length of stay, residential care placement and early mortality can all still arise with sarcopenia, functional decline and multiple pressure injuries, all of which are attributable to hospital-acquired malnutrition.

A further dimension to the implications of malnutrition is the societal consequence of ageing. The increasing burden on the working age population is captured in the Old-Age Dependency Ratio [28, 29], and this emphasises the importance of good nutrition throughout the lifespan. Implications include:

e Society will need older adults to be independent for much longer in the future.

e Survival into old age is not going to be enough; quality of life is more important to older adults than longevity.

e Demographic change is going to be extremely rapid, increasing pressure on health and social care services; society must start adapting and adopting measures immediately.

The challenge of providing nutrition care for ageing populations is multifactorial. Urgent attention is required globally so that older adults and healthcare providers can understand the continuum of nutrition care across the lifecycle. ‘Healthy eating’ and optimal nutrition health during pre-older adult years must provide the groundwork for healthy ageing, but we need to re-evaluate what ‘healthy eating’ looks like in older adults.

The onset of frailty and other conditions of old age requires us to consider changing the focus of nutrition care away from lifestyle advise and the prevention of obesity and towards prevention of functional loss and the maintenance of muscle mass, bone integrity and quality of life.

This may at first appear counter-intuitive, for example, prescribing supplements in an obese inpatient at risk of malnutrition after hip fracture or deprescribing a long-standing ‘low-cholesterol diet’ for someone admitted to a cardiac unit with underlying malnutrition [30, 31]. It may simply mean accepting the risk of aspiration in an older adult with end-stage Parkinson’s disease and allowing them unrestricted food and fluids for the comfort, enjoyment and social interactions that mealtimes offer. When and where such shifts in the focus of nutrition care should occur will depend on age-related changes, comorbidities, sociocultural factors and, most importantly, what matters to the older adult.

1.3 Malnutrition: A Truly Wicked Problem

Malnutrition is multifactorial and underlying factors that can lead to malnutrition are many and varied. In some cases, malnutrition cannot be resolved, although attentive management may improve outcomes for older adults and the systems that care for them. There are no single ‘silver bullet’ solutions; this is one of many reasons why malnutrition is considered to meet the definition of a ‘wicked’ problem as initially described by Rittel and Webber (Table 1.1) [32, 33].

1.4 Building the Rationale for Integrated Nutrition Care

It is important that healthcare providers are proactive in identifying individual causes, signs and symptoms of malnutrition. If identified early, malnutrition can be treated with individualised nutritional intervention plans which should be supported by effective systems and cohesive, integrated care processes [1]. While early recognition and treatment of malnutrition are recognised as beneficial for the health and wellbeing of the older person, nutritional diagnosis and a timely nutrition care can also reduce overall healthcare and community costs [34-36].

Table 1.1 Why malnutrition in older adults should be considered as a wicked problem [32, 33]

e Profession and scientific definitions and diagnostic criteria continually evolve over time

e Shared and overlapping boundaries between ageing, cachexia, frailty, obesity, sarcopenia and other conditions

e Unique individual presentations in ageing limit the usefulness of clinical algorithms and the accuracy of tools

e The diagnosis and related underlying problems cannot be routinely reduced to single-base variables

e The aetiology of malnutrition is multifactorial; underlying factors that can contribute to malnutrition are many and varied

e There are unfixed, iterative and adaptive solutions that require tailoring across settings

e There are no ‘right’ or ‘wrong’ solutions; and in many cases management, rather than resolution, may be appropriate

e There are no ‘silver bullets’ providing all the solutions

e Clinician actions are constrained by a lack of or contradictory evidence, resource limitations, the balance between food as a right to life and food as a medicine and older adult preferences and beliefs

e Intervention and outcome evaluations are routinely confounded by other factors

e Every older adult and setting should be considered essentially unique

Silos Multidisciplinary Interdisciplinary Working independently of Working in parallel or Working together from Working jointly together other disciplines sequentially with other individual disciplinary Transcending disciplinary Ineffective or dis-integrated disciplines perspectives boundaries communication and clinical Shared goals Tendency to maintain Sharing and integrating care Maintains disciplinary disciplinary boundaries knowledge, skills, Guards professional boundaries Common goal focus accountabilities boundaries, knowledge and Focus together on solving real skills world, complex problems

Fig. 1.1 Moving from silos to transdisciplinary care [41, 42]

The nature of nutrition care, and geriatric practice more generally, predicates a comprehensive approach delivered by multiple healthcare providers across the continuum of care [37, 38]. Appropriate nutrition care for older adults is not something that will occur organically, but requires cultivating towards integrated, transdisciplinary approaches to deliver efficient, effective and sustainable nutrition care across acute, rehabilitation and community settings [7, 27, 39, 40]. Multi-agency collaboration; integrated organisational and administrative structures; shared skills, tasks and goals across all relevant actors; collaborative leadership; and, most importantly, a focus on what matters to the older adult are all key components of transdisciplinary care. These are also the necessary ingredients to manage the wicked problem of malnutrition. Consequently, continual progression along the continuum from siloed, single-discipline approaches to transdisciplinary care (Fig. 1.1) is most likely to impact positively on nutrition care.

1.5 Managing the Wicked Nutrition Problems with a SIMPLE Approach (or Other Tailored Models)

The sheer volume of older adults with or at risk of malnutrition or other nutrition-related diagnoses, combined with increasing health expenditure and competing demands for resources, have resulted in demand outstripping supply of individual access to nutrition specialists [22]. Internationally, there are several models available that support interdisciplinary healthcare teams to deliver timely and appropriate nutrition care, for example, the Systematised, Interdisciplinary Malnutrition Program for impLementation and Evaluation (SIMPLE), the More-2-Eat implementation programme targeting improving nutrition culture within hospitals and Malnutrition Universal Screening Tool (MUST) [27, 43, 44].

These models usually triage those screened into one of three groups: those ‘not at risk’ and appropriate for standard care, those who are at risk or malnourished who are appropriate for interdisciplinary or ‘supportive’ nutrition care and those who are likely to benefit from the intervention of a nutrition care specialist, or ‘specialist nutrition care’. Specialised nutritional interventions tailored to individual requirements have demonstrated positive influence on outcomes in the acute and rehabilitation settings [27, 45, 46]. However, for many individuals across diverse geriatric care settings, reliance on ‘specialist’ nutrition care may not add additional benefit to the fundamental nutrition care that could and should be provided by the rest of the team as ‘supportive’ nutrition care. Specialised nutrition care may be delayed because of many diverse reasons, varying from inadequate availability of specialists, no weekend cover or clinical prioritisation requirements, and, in many locations, it may simply not be available because of either lack of funding or the availability of clinicians to fill advertised positions, particularly in rural and remote settings.

1.5.1 Keep It SIMPLE When Appropriate

While recognising that nutrition care in older adults is often complex, in a high proportion of cases and settings, supportive SIMPLE nutrition care is appropriate. Figure 1.2 provides an illustrative summary of how healthcare professionals can contribute to systematised, interdisciplinary supportive nutrition care for individual older adults with, or at risk of, a nutrition-related diagnosis. This figure has been adapted from the SIMPLE model and is composition of key nutrition care models applied internationally [27, 43, 46—48]. This is further detailed in Bell et al. [7].

De I A

Not at risk Low risk High risk

Screened

Fig. 1.2 A SIMPLE nutrition care approach. (Source: Adapted to fit from key nutrition care models [27, 43, 46-48])

1.5.2 A SIMPLE Case Example

An educational case example is now presented to illustrate how the SIMPLE model may be applied across practice settings.

Case Example

Mary is an 83-year-old female with hip fracture, admitted to a hospital with minimal dietetics services. She lost her husband 4 months ago, lives alone and has no children.

Anthropometry: Height 162 cm, weight 82 kg and BMI 32; she has lost 10 kg in the last 6 months secondary to complications after cardiac surgery and sepsis on multiple recent admissions.

Medical history: Type 2 diabetes, high blood pressure, hyperlipidaemia, depressed and excessive alcohol intake.

Pharmacy: Cardiovascular drugs (cholesterol and blood pressure lowering), psychotropic drugs (antidepressant, anti-anxiety and sleeping aid) and oral hypoglycaemic agents for type 2 diabetes.

Day 2 post-op rapport: She has fever and chest infection. She has had hypoactive delirium since admission, and now the medical team is questioning whether she has underlying cognitive impairment and whether she might be drowsy due to overmedication for post-operative pains. She has had poor oral intake since admission. She gets standard hospital diet but without dessert and sweet bread because of her T2DM and obesity. A nurse has noticed that she coughed a couple of times while she was drinking her tea. There is a stage 2 pressure injury on her right heel.

Cases like Mary’s are encountered every day by staff working in geriatric care settings. It highlights the complexity of nutritional issues that need to be considered by the interdisciplinary team but also provides an example for SIMPLE supportive care.

1.5.2.1 S—Screen for Malnutrition Mary will be identified as ‘at risk’ of malnutrition when she is screened using most internationally applied, validated malnutrition screening tools.

1.5.2.2 I—Interdisciplinary Assessment

Unfortunately, in many settings Mary would not have been screened for malnutrition risk and, even if positively screened, may not have met the clinical prioritisation criteria for specialist nutrition care. In many settings globally, access to timely dietitian or medical nutrition specialist care is simply not going to be available for Mary. Whether Mary would meet requirements for ‘supportive’ versus ‘specialised’ care will consequently be dependent on setting, but in this case, we suggest supportive, rather than standard care, should be considered as a minimum.

1.5.2.3 M—Make the Diagnosis (es)

Multiple nutrition-related diagnoses are evident, and the evidence-based recommendations for nutrition care are, at best, difficult to align but are more likely to be conflicting. For example, Mary has diabetes and is overweight, and she reports a long-standing low-cholesterol, ‘low-sugar’ diet; so she is happy about her weight loss. Unfortunately, Mary is also malnourished, in part reflecting restrictive dieting, excessive alcohol intake and poor intake associated with depression and social disconnection. In most settings, this will be the recognised priority in addressing Mary’s nutritional diagnosis.

1.5.2.4 P—Plan with the Older Adult

Identifying the priority diagnosis and balancing nutrition co-diagnoses cannot generally be guided by evidence-based algorithms. Instead, clinical judgement and engagement with the older adult, their family, carers and treating teams are necessary in understanding and definition of shared treatment goals. In such cases, some components of nutrition care may be appropriately delivered by the interdisciplinary team, but only if they ask the right questions and work together with the older adult. What are their requirements and priorities? What does the evidence suggest? What is the treatment intent? What does the older adult want? If nutrition care is genuinely complex and likely to benefit from specialist attention, this should be prioritised wherever resources permit.

1.5.2.5 L—Implement Interventions

An evidence-based, multi-modal, interdisciplinary approach that promotes ‘nutrition as a medicine’, interdisciplinary nutrition care, food-service enhancements, improved nutrition knowledge and awareness and coordination of pre- and post-discharge nutrition care is likely to improve outcomes for older adults like Mary [31].

1.5.2.6 E—Evaluate Ongoing Care Requirements

Ensuring that individual and systems processes for the evaluation of ongoing care requirements are in place is a key component of integrated care. Where possible, engaging the older adult in self-monitoring should be a key priority and supported by post-discharge follow-up of nutrition by a general practitioner.

1.6 Bringing It All Together: Integrated Nutrition Care Across the Four Pillars of (Ortho) Geriatric Care

The following chapters of this book are written with older adults like Mary, and all those who care for her, firmly in mind. Chapters are centred around the key pillars of the call to action for orthogeriatric care [49]. These invoke the need to consider

(1) the core business of primary and secondary prevention strategies, (2) the interdisciplinary management of the acute period and (3) the rehabilitation phase, recognised as continuing for the rest of the older adult’s life.

To support these three clinical pillars, a fourth is highlighted—the political pillar of creating national interdisciplinary alliances between relevant mainstream professional associations, to push for the policy change and multi-professional education that is needed if the first three are to gain impetus.

In considering these fundamental pillars of care, each chapter presents an evaluation of the current evidence for best practice, balanced with ‘in field’ applied understanding regarding how to balance ‘best practice’ with the realities of routinely confounding, and often conflicting, recommendations, conditions, resources perceptions, biases and team and older adult expectations.

The mantra of this book is that we should avoid applying prescriptive ‘must do’ algorithms or formulae, but readers will be challenged to consider their own local context and to decide how to prioritise efficient and effective nutrition care that matters to older adults, in the right place, at the right time, by the right healthcare providers. This approach will also support care across settings, whether medical nutrition specialist access, experiences and resources are readily accessible, limited or simply not available.

The purpose of Chap. 2 is to describe the nutritional recommendations for older adults and introduce the need to consider changes in requirements with age and disease. Chapter 3 shares knowledge about terminology and best practice for the nutrition care for older adult. Chapter 4 is about malnutrition prevention in older adults where many factors influence the nutritional intake, wellbeing and quality of life. This will introduce the need to consider acute or chronic diseases, and a reduced dietary intake plays a crucial role in developing malnutrition. A key aim of this chapter is to increase the nutritional-based knowledge of nurses and other healthcare providers to prevent malnutrition. Chapter 5 describes the practical aspects of nutrition support, including nutritional dense food, nutritional supplements and/or when enteral and parenteral nutrition may be used. The ethical aspects of nutrition support are also considered. This chapter also makes the case that perhaps the most critical tool in a dietitian or medical nutrition specialists toolkit is a clinically focussed food-service system.

Chapter 6 describes opportunities for nursing to demonstrate leadership in nutrition care, whether to supporting healthy eating to sustain healthy ageing and prevent and manage malnutrition; endocrine, immune system and organ dysfunction; muscle strength and function; bone health in older adults; or a combination of these. Considerations regarding assessment of hydration status, recommendations and guidelines for hydration, fluid intake and intravenous fluid therapy are provided in Chap. 7. Chapter 8 aims to untangling ageing, malnutrition, frailty, sarcopenia and function; these are different conditions with overlapping characteristics, consequences and interventional opportunities in older adults. These can often be hidden conditions; hence interdisciplinary awareness is needed for optimal identification and management. Chapter 9 aims to introducing bone health in older adult, what happens with ageing and how we diagnose osteoporosis. What we can do from a nutritional and non-nutritional perspective in preventing osteoporosis and supporting those with osteoporosis?

Many factors influence eating behaviour and nutritional status in older adults. Chapter 10 introduces the need to consider how to increase older adult motivation, factors that support or confound adherence to nutrition care, and reminds readers that eating habits are inseparably linked with people’s physical and psychological health and wellbeing. An overarching aim of this chapter is to assist healthcare providers to consider psychological barriers that may lead older adults away from engaging with nutrition care and the importance of motivational interventions to support adherence to nutrition care. This chapter also provides useful insights and direction for further research.