Hair falling out. Weakness and confusion. Wounds that don't heal.
These can all be signs someone is malnourished, but they are commonly mistaken for the "normal" process of ageing.
"People say 'Oh I'm just getting older' when in fact they're malnourished and it's completely avoidable for many people,"Judi Porter, a professor in dietetics at Deakin University, says.
Older people have higher protein and energy requirements than younger adults but their daily intake is often much lower so malnutrition can creep up easily.
In fact, 68 per cent of people living in aged care are malnourished or at risk of malnutrition. And up to one in two elderly Australians in the community may have an insufficient diet.
"It's a serious problem in Australia," says Karly Bartrim, a dietitian and aged care interest group convenor at Dietitians Australia.
Intervening early is paramount and waiting to get help can be deadly.
"Regrettably, you can die from malnutrition in Australia … people can definitely fade away," Professor Porter says.
Despite the scale of the problem, there are no specific Australian dietary guidelines for older people at risk of malnutrition.
And there's no mandatory malnutrition screening in aged care.
"Malnutrition is so prevalent in aged care but dietitians are only being involved when there's weight loss, which is often a flow-on effect," Miss Bartrim says.
"If we were included earlier we could prevent that weight loss from occurring."
How can it arise?
Loss of appetite or reduced interest in food can happen for a variety of reasons — some physical, some psychological.
Older people carry a large burden of chronic diseases that can alter the appetite, such as kidney and liver disease and congestive heart failure.
And people living with dementia can forget to eat, go shopping or just forget the food they once enjoyed.
"If a family member asks what you had for lunch you might just say 'A sandwich' cause you had a sandwich for the last 80 years but perhaps you didn't actually have the sandwich,” Professor Porter says.
Ill-fitting dentures can discourage someone from eating, and so too can dysphagia, which is when someone has difficulty swallowing.
Poor emotional wellbeing can also turn someone off their food.
Loneliness, which affects one in five older Australians, clinical depression and grief are common causes.
"It happens to thousands of Australians — their mood is low so their appetite drops," Professor Porter says.
"That's about going to see a GP and treating the depression rather than the low appetite."
Food insecurity is another big reason. If someone can't afford to buy nutritious food they may skip meals or eat cheap, unhealthy options.
On top of that, we often take more medications as we age and many can impair the absorption of nutrients including vitamin B12, sodium and magnesium.
What can happen?
If someone loses 5 to 10 per cent or more of their total weight over three to six months that's generally indicative of malnutrition.
But there are other things to look out for.
Energy levels can drop away and a person may not seem themselves as cognitive function and behaviour can be impacted.
Their immune system may also be weaker and they may have poor wound healing.
"We can always tell someone's not eating because it will take forever for the wound to heal," says PhD candidate Miss Bartrim.
They will also likely lose muscle mass as their body is in starvation mode and burning muscle to function.
This can bring on a musculoskeletal disease called sarcopenia, which is when muscle strength, quantity or quality as well as physical performance are compromised.
This can stop someone from getting up and doing the things they enjoy.
"And this leads to people being more socially isolated, often getting depressed, getting lonely, and then that is a feedback loop for them not wanting to bother to eat," Professor Porter says.
People with sarcopenia have a higher risk of falls and fractures and less ability to recover.
"If someone is malnourished and falls they just don't have the reserves in their body to support them," Miss Bartrim says.
A fracture can mean someone ends up in hospital and their condition worsens from hospital-acquired malnutrition, which can affect up to 65 per cent of inpatients.
It's caused by people being in an unfamiliar environment, confused and having little choice over food. On average it means the patient stays in hospital for an extra 21 days.
Changes to diet and meal times can help
Early recognition is the name of the game.
Don't wait to seek help as once muscle is lost it can be really hard to put back on.
"So if you are starting to see mobility changes or changes to weight or eating patterns, I wouldn't hesitate and get a referral for a dietitian," Miss Bartrim says.
And if someone has a chronic disease, they may be eligible for up to five subsidised sessions with an allied health professional such as a dietitian or an exercise physiologist, who can help with rebuilding muscle mass.
But there are simple diet changes that can be made right away.
The emphasis for older people needs to be on eating foods that are high in protein and energy, which means vegetables take a bit of a back seat.
"People say to me 'Ok well I better go home and eat more vegetable soups and salads' but they shouldn't fill up on that, it exacerbates the problem as there's no energy in those," Professor Porter says.
And don't buy the "diet" or "low-fat" options. Having some extra kilos as an older person is protective; it can be the padding that protects against a fracture if there's a fall or the extra energy needed when undergoing chemotherapy.
"We tell people the opposite to what they're told as children," Miss Bartrim says.
"Don't skip dessert, have the ice cream."
But how do you eat more when you don't feel like it?
A technique called "eating by the clock" can help establish a routine if your appetite has decreased and you need mental prompts to eat.
It involves eating six small meals at the same time each day, even if you're not hungry.
Nutritional supplement drinks between meals are better than just tea or coffee but food should always be the first option.
"We know people get a lot more joy out of eating food than drinks," Miss Bartrim says.
And finally, family members should try not to make meal times stressful by putting lots of pressure on someone to eat. Take a social approach, choose comfort foods and don't rush.
The bigger picture
The current Australian dietary guidelines do not include "frail, elderly people at risk of malnutrition" who are defined as "usually" being over the age of 75.
The guidelines say it's because this group have "complex health needs" and health professionals should be consulted for advice.
However the National Health and Medical Research Council (NHMRC) is currently reviewing the guidelines and the updated version will include those 65 and older and provide advice on preventing malnutrition, frailty, falls and chronic conditions.
The updated guidelines are expected to be released in 2026.
Miss Bartrim says it will be helpful to have specific advice the community and meal providers can look to but more change is needed.
She and many other dietitians want the government to introduce mandatory malnutrition screening in aged care.
They're calling for increased funding so residents can be screened at the beginning of care and on a regular basis and so dietitians can be involved as soon as someone is at risk.
"Currently, a lot of the model is just working around treatment and fixing [malnutrition] when it's too late. But we can put steps in place to prevent it in the first place," Miss Bartrim says.
A spokesperson for the federal Department of Health says the new Aged Care Act, due to commence next year, will prescribe food and nutrition standards that providers must adhere to.
Menus must be developed with the input of an accredited dietitian and be reviewed at least annually by a dietitian, according to the draft quality standards that will accompany the new Act.
Malnutrition screening is recommended as a way for providers to show they are meeting quality standards, but is not mandatory.
Find out more about how to improve the quality of life for older Australians in care on Maggie Beer's Big Mission on Tuesdays at 8.30pm on ABC TV or catch up on ABC iview.
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