# A nurse is assessing nutritional status in an 82-year-old client during an annual wellness visit. The client lives alone and reports decreased appetite over the past 3 months. Which actions reflect evidence-based geriatric nutritional assessment? Select all that apply.

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> subject: Assignment/Delegation/Supervision  
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## Question

A nurse is assessing nutritional status in an 82-year-old client during an annual wellness visit. The client lives alone and reports decreased appetite over the past 3 months. Which actions reflect evidence-based geriatric nutritional assessment? Select all that apply.

1

Use the Mini Nutritional Assessment (MNA) or MNA-Short Form screening tool to identify malnutrition risk in older adults

2

Recommend bed rest and minimal physical activity to conserve energy and weight in older adults with decreased appetite

3

Assess for unintentional weight loss of 5 percent or more in 1 month, or 10 percent or more in 6 months, as a warning sign of malnutrition

4

Use BMI alone as the primary indicator of nutritional status, because BMI accurately captures muscle mass and fluid status in older adults

5

Assess for hidden barriers to adequate intake, including dental problems, medications causing dry mouth or anorexia, food insecurity, social isolation, depression, and swallowing difficulty

6

Restrict protein intake to 0.5 g/kg/day in all older adults to prevent renal stress, regardless of activity level or comorbidities

## Explanation

Use a validated older-adult nutrition screen such as the MNA or MNA-SF (Choice 1). Assess recent unintentional weight loss because 5% in 1 month or 10% in 6 months is a major warning sign (Choice 3). Identify barriers such as dental problems, medication effects, food insecurity, isolation, depression, and dysphagia so interventions address the cause (Choice 5). Bed rest and activity restriction worsen deconditioning and sarcopenia (Choice 2). BMI alone can miss low muscle mass or fluid-related weight changes and must be combined with weight trends and functional assessment (Choice 4). Routine severe protein restriction is not appropriate for every older adult and can worsen sarcopenia; intake should be individualized for renal function, illness, and activity (Choice 6).

## In-depth explanation

Geriatric Nutrition Screening — MNA
Mini Nutritional Assessment (MNA) — validated 18-item tool. Short form (MNA-SF, 6 items) commonly used:
1. Decline in food intake past 3 months
2. Weight loss in 3 months
3. Mobility
4. Recent stress or acute disease
5. Neuropsychological problems
6. BMI (or calf circumference if BMI unavailable)
Score: 12-14 normal, 8-11 at risk, 0-7 malnourished.

Older Adult Nutrition Targets
- Protein 1.0-1.2 g/kg/day (1.2-1.5 with acute illness or sarcopenia) — prevents sarcopenia
- Calories ~30 kcal/kg/day; adjust for activity
- Fluids 1.5-2 L/day unless restricted
- Vitamin D, B12, calcium commonly low

Hidden Barriers
"DETERMINE" mnemonic: Disease, Eating poorly, Tooth/mouth, Economic hardship, Reduced social contact, Multiple medications, Involuntary weight, Needs assistance, Elder years (above 80).

Memory Tip
"5/10 weight loss rule": ≥ 5% in 1 month or ≥ 10% in 6 months = significant.

Caution
Routine protein restriction is harmful unless specific medical indication (advanced CKD without dialysis). Sarcopenia prevention is more important than feared kidney load in most older adults.

## Clinical scenario

Scenario
82 y.o., living alone, annual visit. Reports decreased appetite × 3 months. Spouse died 6 months ago. Wears partial dentures, complains they hurt while eating. Takes 8 medications. Weight 58 kg (was 64 kg 6 months ago — 9% loss). BMI 21.

MNA-SF Today
1. Food intake decreased moderately = 1
2. Weight loss > 3 kg = 0
3. Mobility OK = 2
4. No acute disease = 2
5. Mild dementia (cognitive screen Q) = 1
6. BMI 21 = 2
Total = 8 → at risk for malnutrition

Intervention Plan
- Dental referral for denture adjustment
- Pharmacist medication review (drug-induced anorexia/dry mouth)
- Depression screen (PHQ-2 first, then PHQ-9)
- Refer to community meal program (Meals on Wheels) for social and nutritional support
- Dietitian referral for individualized plan, protein 1.2 g/kg/day target
- Oral nutritional supplement BID between meals
- Follow-up weight in 4-6 weeks

Avoid
- Routine protein restriction
- Bed rest recommendations
- BMI alone as marker

## Key concepts

- **Mini Nutritional Assessment (MNA)** — Validated nutritional screening tool specifically for adults 65 and older. Full version 18 items, short form (MNA-SF) 6 items. Screens recent food intake, weight loss, mobility, stress/disease, cognitive/psychological status, and BMI. Score categories: 12-14 normal nutrition, 8-11 at risk for malnutrition, 0-7 malnourished. MNA-SF is endorsed by ESPEN.
- **Significant unintentional weight loss** — Important malnutrition warning sign in older adults: ≥ 5% body weight loss in 1 month, or ≥ 10% in 6 months, when not intended. Triggers nutritional assessment, evaluation for underlying disease (cancer, depression, hyperthyroidism, infection), medication review, and intervention plan.
- **Sarcopenia** — Age-related loss of skeletal muscle mass and strength, accelerated by inactivity, inadequate protein intake, and acute illness. Increases fall risk, disability, and mortality. Prevention/treatment: resistance exercise, adequate protein 1.0-1.2 g/kg/day (1.2-1.5 with acute illness or established sarcopenia), vitamin D adequacy. BMI does not detect; check grip strength and gait speed.

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