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Nutrition for vulnerable groups

A key challenge of caring for vulnerable patients is the prevention of malnutrition and dehydration. Malnutrition and dehydration are common but often go unrecognised and untreated (1). 

More than 10 per cent of people aged 65 years and over are malnourished and 70 per cent of undernutrition in the UK is unrecognised (2). Malnutrition and dehydration were identified as underlying causes and contributing factors in the deaths of more than 650 care home residents between 2005 and 2009 (2).

Human cost

Malnutrition and dehydration greatly increase an individual's vulnerability to illness, clinical complications and death (3). Dehydration is one of the risk factors for falls in older people and is associated with pressure ulcers, faecal impaction and cognitive impairment (4).The clinical effects and consequences of malnutrition are wide ranging. Impaired immune response can weakenthe ability to fight infection. Reduced muscle strength and fatigue can impede self-care and may result in falls. In bed-bound patients this can result in pressure ulcers and blood clots.

Financial cost

According to Malnutrition Pathway (6), disease related malnutrition costs the NHS  more than £13 billion per year based on malnutrition figures and the associated costs of both health and social care (6). A saving of just one per cent of the annual health care cost of malnutrition to the NHS would amount to £130 million annually (8).

Public awareness

A report from Carers UK (10) based on the experiences of more than 2,000 carers says that malnutrition can be a hidden issue. Carers may be unaware of where best to seek help, and can feel isolated and guilty that the person they are caring for is becoming malnourished, according to the report.

The state of services

Screening and planning for effective nutrition and hydration, coupled with quality food and beverage services and appropriate nutritional support are needed in all care settings. This includes considerations around enteral and parenteral as well as oral nutrition (2). Evidence collected by Age UK suggests that the reality falls short of what is needed (1; 11). Concerns have also been raised about monitoring and reviewing processes in the administration of parenteral nutrition to ensure effectiveness and safety (12).

Identifying factors, targeting actions

Several factors reduce the effectiveness of services (3). These include lack of prioritisation of nutritional care, lack of awareness of the multiple impacts of malnutrition and hydration and the lack of trained staff.

Research literature from the University of Birmingham has noted the need to move from identifying concerns about nursing performance to targeting actions designed to alleviate contributing factors. This includes an understanding of the pressures of the healthcare environment and the demands of productivity and performance.

Nutrition and hydration present a specific set of challenges and need the attention and visible effort given to other patient safety issues (15). Early identification and intervention are essential.

Guidance documents and tools have been developed across the UK in response to these challenges. See the Nutrition – improvement actions page in this Clinical Topic for tools and approaches. 


These resources were last accessed on 7 December 2015. 

  1. BAPEN (2012) Toolkit for Clinical Commissioning Groups and providers in England: Malnutrition matters: meeting quality standards in nutritional care 2nd ed (PDF 4.6MB), Redditch: BAPEN.
  2. RCN (2006) Malnutrition: what nurses working with children and young people need to know and do. An RCN position statement, London: RCN. [Available in print from RCN Library and Heritage Centre].
  3. Joosten KF, Hulst JM (2008) Prevalence of malnutrition in pediatric hospital patients, Current Opinion in Pediatrics, 20(5), pp.590-596.
  4. More J (2008) Don't forget the undernourished children in our midst, Journal of Family Health Care, 18(5), pp.159-160.
  5. Patients Association (2011) Malnutrition in the community and hospital setting (PDF 412.79KB), Harrow, Middlesex: Patients Association.
  6. European Nutrition for Health Alliance (2006) Malnutrition among older people in the community: policy recommendations for change, London: ENHA.
  7. Nursing Standard (2009) Nutrition and older people, Harrow, Middlesex: RCN Publishing Company. (You can access the full text of this publication if you are a registered subscriber to Nursing Standard. Hard copies of the booklet are also available in the RCN library).
  8. Heath H and Phair L (2011) Frailty and its significance in older people's nursing, Nursing Standard, 26(3) 21 September, pp.50-55. [Full text is available through the RCN e-library via the e-journals].
  9. NHS Quality Improvement Scotland (2009) Prevention and management of pressure ulcers – best practice statement, Edinburgh: NHS QIS (made available on the Healthcare Improvement Scotland website).
  10. Patient Safety First (2009) The ‘How to’ guide for reducing harm from falls, London: Patient Safety First.
  11. Rowat A (2011) Malnutrition and dehydration after stroke, Nursing Standard, 26(14) 7 December, pp.42-46.
  12. Alzheimer's Society (2012) Caring for a person with dementia. Everyday care: eating. Alzheimer’s Society website.
  13. Social Care Institute for Excellence (2010) Dementia Gateway: eating well for people with dementia, SCIE website
  14. National Patient Safety Agency (2007) Ensuring safer practice for adults with learning difficulties who have dysphagia, NPSA website.
  15. RCN (2011) Meeting the health needs of people with learning disabilities: RCN guidance for nursing staff (PDF 1.7MB) 2nd.ed., London: RCN.
  16. Royal College of Physicians (2010) Oral feeding difficulties and dilemmas: a guide to practical care, particularly towards the end of life, London: RCP.