What is the recommended multidisciplinary rehabilitation program for an elderly (≥65 years) patient with reduced oral intake, weight loss, low muscle mass and frailty?

Rehabilitation of Malnutrition and Frailty in Elderly Patients

Elderly patients (≥65 years) with reduced oral intake, weight loss, low muscle mass and frailty require a multidisciplinary team intervention combining enhanced nutritional support with structured exercise programs to improve functional outcomes, reduce complications, and maintain independence. 1

Core Multidisciplinary Team Composition

The rehabilitation team must include: 1, 2

• Dietitian for nutritional assessment and intervention planning
• Physical therapist for exercise prescription and mobility training
• Geriatrician or physician for medical management and coordination
• Nurse for daily care implementation and monitoring
• Social worker for psychosocial support and resource coordination
• Occupational therapist for activities of daily living training
• Kitchen/housekeeping personnel for meal preparation and delivery 1

Nutritional Intervention Strategy

Energy and Protein Requirements

Calculate individual energy needs before starting interventions, then provide: 1

• Energy intake: Total energy expenditure (TEE) plus 250 kcal/day if goal is 1 kg weight gain over 30 days 3
• Protein intake: 1.2-1.5 g/kg/day, distributed evenly throughout the day 2, 3
• This positive energy balance is critical during exercise periods to prevent further muscle catabolism 1

Specific Nutritional Components

Implement the following nutritional strategies: 1

• Energy- and protein-enriched meals as the foundation of dietary intake 1
• Oral nutritional supplements (ONS) when dietary counseling alone is insufficient 2
• Protein and vitamin D enriched supplements specifically during exercise training 1
• Calcium and vitamin D supplementation for bone health 1
• Daily multivitamin for those consuming <1500 kcal/day 1
• Consider vitamin B12 and folate supplementation, particularly if deficiencies identified 1

Meal Delivery and Assistance

Provide practical mealtime support: 1

• Mealtime assistance from trained staff to help with food selection and eating 1
• Preferred food choices to maximize voluntary intake 1
• Snacks between meals to increase total daily intake 1
• Liberalize dietary restrictions that may reduce intake 2

Exercise Prescription

Multicomponent Exercise Program Structure

Prescribe the following exercise regimen, totaling 50-60 minutes daily (can be distributed throughout the day): 1

Aerobic Exercise: 1

• 10-20 minutes per session
• 3-7 days per week
• Intensity: 12-14 on Borg scale (55-70% heart rate reserve)

Resistance Training: 1

• 1-3 sets of 8-12 repetitions
• 2-3 days per week
• Start at 20-30% of one-repetition maximum, progress to 60-80%
• Incorporate functional daily activities

Balance Training: 1

• 1-2 sets of 4-10 different exercises
• 2-7 days per week
• Target both static and dynamic postures

Gait Training: 1

• 5-30 minutes daily
• Focus on walking ability and endurance

Critical Exercise-Nutrition Integration

Never prescribe exercise without ensuring adequate energy and protein intake—this is the most common pitfall. 1 Studies consistently show that exercise alone in malnourished patients leads to weight loss and muscle catabolism when energy balance is negative. 1 Combined interventions show superior outcomes for body weight, muscle mass, and functional measures compared to exercise alone. 1

Comprehensive Assessment Requirements

Identify and Address Underlying Causes

Systematically evaluate and eliminate: 1

• Swallowing difficulties requiring formal swallowing evaluation
• Dental problems through dental examination
• Medications causing anorexia, xerostomia, dysgeusia, or GI disturbances 2
• Depression (refer if GDS-5 score ≥2) 2
• Cognitive impairment affecting eating ability
• Social isolation and lack of support 2

Nutritional Status Monitoring

Track the following parameters: 2

• Weight measurements at regular intervals
• Mini Nutritional Assessment (MNA) scores 1
• Dietary intake (energy and protein)
• Functional measures (grip strength, mobility, ADL independence)
• Body composition when possible

Intervention Duration and Continuity

Continue interventions for minimum 3 months, with effects persisting post-intervention. 4 The evidence shows: 1

• Nutritional interventions extended to 3-6 months post-hospitalization improve outcomes 1
• Multifactorial interventions for 3 months reduce frailty prevalence by 23.5% and improve functional health 4
• Effects fade when nutritional care is discontinued, emphasizing need for ongoing support 1

Expected Outcomes and Monitoring

Primary Outcomes to Track

Monitor for improvements in: 1

• Reduced complications (infections, pressure ulcers, falls) 1
• Improved functional independence in ADLs 1
• Better mobility and physical performance 1
• Reduced delirium days in hospitalized patients 1
• Improved quality of life 1
• Decreased mortality risk (in some populations) 1

Cost-Effectiveness Considerations

Multidisciplinary interventions are cost-effective, showing: 1

• Reduced length of hospital stay 1
• Fewer emergency department visits 1
• Lower nursing home admission rates 1
• Reduced healthcare costs overall 1

Special Populations and Contraindications

When Aggressive Nutrition Therapy is Indicated

Implement aggressive nutritional support (TEE + energy accumulation) for: 3

• Precachexia states
• Mild to moderate dementia with maintained activity
• Post-hip fracture or orthopedic surgery patients 1

When to Exercise Caution

Aggressive nutrition therapy is contraindicated in: 3

• Refractory cachexia
• Acute disease with severe inflammation
• Bedridden patients with severe dementia and minimal activity
• These patients require palliative care discussions and goals-of-care conversations 2

Implementation Pitfalls to Avoid

Common errors that undermine rehabilitation success: 1

• Starting exercise without ensuring adequate energy/protein intake (leads to further muscle loss)
• Discontinuing nutritional support after hospital discharge (effects fade rapidly)
• Failing to address underlying causes of poor intake (medications, depression, dental issues)
• Implementing single interventions rather than comprehensive multimodal approach
• Not involving family members and caregivers in the care plan
• Inadequate monitoring of adherence and response to interventions