Pain management plays an often overlooked yet crucial role in preventing and reducing malnutrition in older adults, particularly within health and social care settings. Pain and nutrition are closely linked and addressing pain effectively can support both physical health and overall wellbeing.
Understanding malnutrition in older adults
Malnutrition is characterised by insufficient intake of energy, protein or nutrients and is particularly detrimental for older adults and individuals with conditions such as dysphagia, which makes it difficult to swallow.
Often an under-recognised and undertreated condition, malnutrition can have severe consequences, including increased vulnerability to illness, delayed recovery and higher mortality rates.
Common consequences of malnutrition include:
- Weakened immune systems, often leading to higher infection risks
- Muscle wastage and frailty, reducing mobility and independence
- Slower recovery from illness or surgery, prolonging hospital stays
- Poor mental health, with increased depression, confusion and lethargy
Older adults are often more at risk of malnutrition due to factors such as decreased appetite, medical conditions and mobility limits.
The scale of the issue in the UK
It is estimated that malnutrition affects more than 1.3 million people over the age of 65 in the UK. While most of those affected live in the community, 30-42% of residents admitted to care homes are at risk. Between 50-60% of residents in care homes overall are malnourished or at risk of malnutrition, significantly contributing to healthcare burdens, poor outcomes and longer hospital stays.
The cost of treating someone who is malnourished is approximately three times the cost of treating someone who isn’t. Estimates suggest that malnutrition may cost the health and social care system as much as £22.6 billion a year. Malnourished individuals are more likely to visit their GPs, have a greater risk of complications in illnesses and are more likely to need hospital and care home admission, putting further strain on the healthcare system.
Current regulations
Under the Health and Social Care Act 2008, it is the care home’s responsibility to ensure that residents have enough to eat or drink to meet their nutrition and hydration needs and receive the support they need in order to do so. The nutritional needs of residents must be assessed and reviewed regularly, and food and hydration provided to meet those needs.
The NICE quality standard for nutrition support in adults (2012) recommends that nutritional screening is undertaken using a validated screening tool, the most popular in the UK being the Malnutrition Universal Screening Tool (MUST). This is an evidence-based method for detecting malnutrition and is validated for use in hospitals, out-patient clinics, GP practices, care homes and the community.
A report by the British Association for Parenteral and Enteral Nutrition (BAPEN) found that while nutrition screening was standard in 90% of UK care homes, there were inconsistencies in using and calibrating the equipment as well as translating the findings into care plans for individuals. This showcases the critical need for full team training, support in care settings and an integrated system to effectively manage and reduce the risk of malnutrition.
How pain directly contributes to malnutrition
Older adults who are experiencing unmanaged pain often have reduced appetite due to discomfort or nausea, difficulty concentrating on eating, and fatigue which can make meals feel overwhelming. All of these factors can lead to them missing or eating reduced meals, ultimately leading to malnutrition.
- Chronic or acute pain can limit an older person’s ability to:
- Sit upright and comfortably during meals
- Chew or swallow due to jaw neck or dental pain (this could be due to poorly fitted dentures or tooth decay)
- Use cutlery due to arthritis or neuropathic pain
Persistent pain is strongly linked to depression, anxiety and social withdrawal – all factors which are known contributors to poor nutrition in older adults. Chronic pain can also increase physiological stress and inflammation which may increase energy requirements, accelerate muscle breakdown and worsen frailty, making receiving the correct nutrition more important than ever.
Impact of medications
Poorly managed pain often leads to overuse of medications such as opioids or psychotropics, which have side effects that include nausea, constipation and dry mouth.
Sedation that interferes with eating is often a result of poorly managed pain; this could include the use of benzodiazepines during mealtimes. Where possible, should be avoided for older people as they are associated with well documented negative side effects, such as the increase in falls and fall related fractures. They can also be associated with increased cognitive decline for people living with dementia.
Jo Hadfield-Cubbin, Head of Clinical Governance at Dovehaven Care Homes, a leading care group in the Northwest of England, said:
“Since implementation of PainChek® across all Dovehaven Care Homes we have seen a transformation in relation to pain management which has significantly reduced distressed reaction behaviours and PRN benzodiazepine use has been reduced by 40%.”
This emphasises how effectively managed pain can reduce the use of medications, which impact appetite and can lead to residents becoming malnourished.
The importance of pain management
When pain management is prioritised, staff are more likely to notice changes in eating habits and be able to address these as soon as possible. Care plans that address both pain and nutrition together are particularly important in older adults with dementia, as they may express pain through reduced eating rather than verbal complaints.
Using PainChek® as a pain assessment tool can enable care providers to identify if a resident is in pain, which may be the cause of their malnutrition. PainChek® is also integrated with nutritional screening tools, such as MUST, so care providers will easily be able to take a holistic approach to their support.
The Scottish Care Inspectorate independently piloted PainChek® for six months and found a 47% increase in resident BMI and subsequent reduction in MUST scores following the use of the tool to identify pain at a much earlier stage. Over a six-month period, 81% of residents at Kirk Lane Nursing Home, part of Randolph Hill group, reduced or maintained their MUST scores and 43% achieved an increase in BMI.
Operational impact of malnutrition
Malnutrition has a significant impact on care homes at a site level. Pain causes increased fraility and requires greater care needs, leading to higher costs to the care provider. These needs can include measures such as assisted feeding and repositioning of the resident to prevent pressure sores, for example, putting greater stress on the workforce.
Indeed, treating pain can reduce malnutrition-related costs, such as the need for supplementary drinks. Manchester House Care Home in Southport, part of the Dovehaven Group, found that many residents who had previously been hospitalised had been prescribed supplementary drinks to target weight loss, causing them to be full during mealtimes and miss out on the nutrients and calories they would gain from balanced meals.
Rachel Preston, Manager at Manchester House said: “We have found that by carrying out regular PainChek® assessments, we have been able to successfully identify that pain was affecting the residents’ daily living, significantly impacting their appetite.
“If the pain is identified and managed successfully then the need for supplementary drinks is reduced, if not negated completely. By treating the source of the pain and achieving a successful pain management regime, the person’s appetite will increase, and their nutritional status naturally improves.
“PainChek® enables us to improve people’s quality of life through monitoring and signposting, and we are grateful for this groundbreaking tool.”
These results highlight the close link between pain and malnutrition and emphasise the importance of implementing effective pain management for those at risk.
To find out more about the impact PainChek® has and the ways in which it can be used to improve care for older adults, read some of our case studies.
