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Introduction

Refusal to eat and drink is a common and distressing precursor to malnutrition for older adults in both institutional and community settings. Malnutrition from inadequate food intake is responsible for 40 out of every 100,000 deaths in adults over age 85.1 Causes of refusal to eat and drink may include physiologic changes associated with aging, mental disorders including dementia and depression, medical, social, and environmental factors.2 Many older adults experience a decrease in body weight as result of aging, together with decreased energy intake, decreased basal metabolic rate, decreased lean body mass, decreased appetite, decreased satiety, and decreased sense of taste and smell.2 Refusal to eat and drink is common among patients with cerebrovascular disease, dementia, and Parkinson’s disease who have difficulty expressing wishes and have mechanical difficulties with chewing and swallowing.2 A phenomenon known as idiopathic senile anorexia, or late-onset anorexia nervosa, may also underlie refusal to eat. These patients are less like to experience disturbed body image and preoccupation with weight, eating, and shape, and more likely to exhibit persistent depressed mood. These patients may feel like eating is meaningless as death approaches.2 Sociocultural and environmental factors also contribute to poor intake. Residents of long-term care facilities who are non-English speaking, have absent family members, and have a diagnosis of dementia tend to have high rates of poor intake.1

Interprofessional Assessment and Collaborative Interventions

It is important that the interprofessional team promptly address patients’ refusal to eat and drink, as older adults with insufficient intake are prone to developing chronic dehydration. Approximately 65% of residents from long-term care facilities brought to the emergency department show signs of chronic dehydration.1 As the body ages, patients are less likely to respond to usual triggers of thirst such as fluid deprivation and increased metabolism. These physiologic changes, along with the inability to concentrate urine in a state of hypovolemia, loss of lean muscle mass, and insensitivity to the antidiuretic hormone, cause older adults to be more at risk for dehydration. In turn, chronic dehydration will lead to changes in medication absorption, development of delirium and fatigue, and increased morbidity and mortality in older adults.1 When patients show signs and symptoms of dementia, risk of chronic dehydration is sharply increased. These individuals often undergo weight loss and wasting as result of forgetting to eat and a complex interplay of biopsychosocial factors. Eating and drinking are neurologically complex processes that involve the ability to recognize food and drink, transfer to the mouth, and swallow, which may be disturbed in individuals with dementia. As dementia progresses, patients are likely to exhibit paranoia, agitation, and resistance during mealtimes that must be addressed by caregivers.1,2,3 Provision of food and fluids by hand should be continued as long as possible. Artificial nutrition and hydration is not recommended in the later stages of dementia as it has been found to have no effect on length of life, reduction of complications such as pressure ulcers, and weight gain. These interventions have also been found to increase the risk of aspiration pneumonia and restraint use in this population. Patients with difficulty swallowing food or refusal to eat to the extent that they cannot maintain sufficient fluid and calorie intake are eligible for hospice benefits through Medicare.1

All members of the interdisciplinary team can positively impact care of the patient who is refusing to eat or drink.1,2 Health care professionals must first evaluate patient  for dysphagia, dementia, depression, organic disease, self-destructive behavior, and medication use to determine the underlying cause of the refusal.2 Nurses and providers are advised to complete repeated assessment of patient’s intake using validated tools such as the Mini Nutritional Assessment (MNA) to guide interventions. Once baseline intake is established, the patient will likely require assistance by staff to increase intake. Nationally, 25% of long-term care residents require either extensive or total assistance with consuming food or fluids.1 Current hydration guidelines advocate for consistent provision of fluids, with 75 to 80% given at meals and the remainder given throughout the day.1 The team should recognize that patients with dementia respond well to routine. Meal times should be planned for times when the patient is well rested. The context of meals is also important. Consistency of caregivers, environment, and food items can provide critical cues that encourage patients to eat independently. Staff should provide companionship during meals and try to enhance the taste, appearance, and presentation of foods help improve intake.1,2 Patients should be observed carefully while eating, with staff keeping a steady pace in feeding and resting when needed to ensure that patient is positioned well and swallowing appropriately. Patients are likely to be easily distracted and may need reminders to keep mouth closed, chew, and swallow. Staff can provide visual and auditory assistance, such as eye glasses and hearing aids, if needed.1

Older adults may have other health problems that compromise their ability to eat, such as arthritis and tremors.1 Patients with acute conditions such as pneumonia and urinary tract infection may have decrease in appetite while patients with end-stage cardiac failure are likely to have anorexia secondary to early satiation from abdominal edema.1,2 Physicians, nurse practitioners, and physician assistants will evaluate the status of these comorbid conditions to determine impact on feeding and plan care accordingly.Providers and pharmacists should review patients’ medications for those that may cause weight loss, nausea, vomiting, and alter taste and smell.2 Pharmacists can also recommend medications to stimulate appetite such as megesterol acetate, as well as digestive aids and analgesics to ease the act of eating and digestion.1,2 Occupational therapy can assess need for adaptive and posturing devices to facilitate eating. Speech and language pathologists can assess capacity for swallowing different consistencies of food and teach swallowing techniques.1 Registered dietitians will review patient’s diet for adequate caloric intake and make recommendations for nutritional supplementation based on patient history, assessment, and swallow evaluation.1,2 Dentists can assess the impact of patient’s present oral health on ability to eat and drink.1 Nurses in home care and long-term care facilities can monitor patient’s eating and drinking behaviors and arrange for intervention and supervision when needed. Social workers can connect patient to appropriate resources in the community.1 Health care organizations and agencies are encouraged to provide education to all staff members on proper identification and management of patients refusing to eat and drink, and to ensure adequate staffing and supervision of patients during mealtimes to improve outcomes.1

Interprofessional contacts for this topic:

Primary care providers

Acute care providers

Registered nurses

Pharmacists

Registered dietitians

Speech-language pathologists

Social workers

Physical therapists

Occupational therapists

Home health aides

Dentists

Link to the following evidence-based protocols:

Age-related changes

Family caregiving

Function

Mealtime difficulties

Medication

Nutrition in the elderly

References

1Amella, E.J. (2004). Feeding and hydration issues for older adults with dementia. Nursing Clinics of North America, 39(3), 607-623.

2Marcus, E.L., & Berry, E.M. (1998). Refusal to eat in the elderly. Nutrition Reviews, 56(6), 163-171.

3Aselage, M.B. (2010). Measuring mealtime difficulties: Eating, feeding and meal behaviours in older adults with dementia. Journal of Clinical Nursing, 19(5-6), 621-631.