Nutrition Risk Assessment (NRA)

Instructions for completing the Nutrition Risk Assessment (NRA)

DETERMINE Your Nutritional Health

Nutrition Screening Initiative (NSI)

Background – The Nutrition Screening Initiative (NSI) was developed in order to address the prevalence of malnutrition among older adults. This initiative represents the work of the American Academy of and the American Dietetic Association to create a coalition whose goal is to promote the integration of nutrition screening and intervention into healthcare for older adults. NSI helps to increase older adults’ awareness about nutrition and health. It differentiates among adequate status, malnutrition risk and malnutrition.

The checklist is based on the following warning signs for poor nutrition:


Eating Poorly

Tooth Loss/Mouth Pain

Economic Hardship

Reduced Social Contact

Multiple Medicines

Involuntary Weight Loss/Gain

Needs Assistance in

Elder Years Above Age 80

DETERMINE was designed by the American Academy of Family Physicians, the National Council on the Aging and others as part of the Nutrition Screening Initiative. This tool can be used by professionals working with elders in order to assess their risk for poor nutritional status or malnutrition. The DETERMINE questionnaire can also be used to measure an individual’s change in level of nutritional risk over time. If DETERMINE scores taken prior to beginning a new nutrition program are compared with scores later in the program, a decrease in the resulting score would indicate a corresponding decrease in the elder’s nutritional risk. In this way, the effectiveness of the program for the individual can be evaluated.


The U.S. Administration on Aging (AoA) require nutrition programs funded by the Older Americans Act and Area Agencies on Aging (AAA) providing nutrition counseling to identify persons at high nutritional risk. Form #AIAAA_NRA_ES 2.0 Edition Date: 5/7/10

Individuals at high nutritional risk are defined by AoA as individuals who score “six (6) or higher on the DETERMINE Your Nutritional Health checklist published by the Nutrition Screen Initiative.” This definition is included in the National Aging Program Information System (NAPIS) State Program Report.

The DETERMINE Your Nutritional Health checklist must be completed annually for all consumers receiving congregate meals, home delivered meals or nutrition counseling. The results of the completed checklist must be entered in the SAMS system for every consumer receiving one or more of these . The content for this form is required and may not be altered by the AAA.



The Warning Signs of poor nutritional health are often overlooked. Use this checklist to find out if you are at nutritional risk.

Read the statements below. Circle the number in the “Yes” column for those that apply to you. Add the circled numbers to get your total nutritional risk score. YES  
I have an illness or condition that made me change the kind and/or amount of food I eat. 2
I eat fewer than two meals a day. 3
I eat few fruits or vegetables, or milk . 2
I have three or more drinks of beer, liquor or wine almost every day. 2
I have tooth or mouth problems that make it hard for me to eat. 2
I don’t always have enough money to buy the food I need. 4
I eat alone most of the time. 1
I take three or more different prescribed or over-the-counter drugs a day. 1
Without wanting to, I have lost or gained ten pounds in the last six month. 2
I am not always physically able to shop, cook and/or feed myself. 2

Total Score                                                                                                       

0-2 = Good Nutritional Health

Recheck your nutritional score in 6 months

3-5 = Moderate Nutrition Health

See what can be done to improve your eating habits and lifestyle. Your Office on Aging Senior Nutrition Program, Senior Citizens or Health Department can help. Recheck your nutritional score in 3 months

6 or More = High Nutritional Risk

Bring this checklist the next time you see your doctor, dietitian or other qualified health or social service professional. Talk with him or her about any problems you may have. Ask for help to improve your nutritional health.

Use the word DETERMINE to remind you of the warning signs.

Disease, illness, or chronic conditions affect the way that people eat. Confusion or memory loss can make it hard to remember what, or whether, they have eaten a meal. Feeling depressed can affect appetite, digestion, energy level, weight, and well-being.

Poor nutritional health can be caused by eating too little, eating too much, skipping meals, or eating the same foods day after day. It can also be caused by eating too few fruits, vegetables, or milk products

Missing or loose teeth, or poor-fitting dentures, can make it hard to eat.

People on a reduced income may find it hard to afford the foods they need.

Having fewer contacts with other people can have a negative effect on morale, well-being, and appetite.

Growing old may change the way that older adults respond to these medicines. The more medicines that they take, the greater the risk for side effects such as constipation, diarrhea, drowsiness, nausea, or a change in appetite or taste.

This is an important warning sign that should not be ignored.

Some older adults have trouble walking, shopping, or buying or cooking food.

Most older people lead full and productive lives. But as age increases, the risk of frailty or health problems increases.

medicines and older adults – the food-medicine connection

Most older adults take medicines. This includes over-the-counter and prescription drugs. Learn how to take them in a way that promotes good health.

Food and medicines play a role in good health. But when taken together, they may affect each other.

Medicines May Affect Food Intake.

  • Medicines may affect the appetite.
  • Medicines may change the taste or smell of foods.
  • Medicines may cause nausea or vomiting.
  • Some medicines should be taken on an empty stomach. Others should be taken with food.
  • It may be harmful to drink alcohol while taking some medicines.

Foods May Affect How Medicines Work.

  • Some foods affect the way the body uses medicines.
  • Some foods may have bad effects when combined with certain medicines.

Take medicines as prescribed. –Ask your doctor or pharmacist:

  • What time of day to take the medicines.
  • If you should stop eating any foods when taking them.
  • If you need any nutrient supplements while taking medicines.
  • What possible side effects to expect.
  • If the dose of long-term drugs should be adjusted over time.

Tell the doctor and pharmacist about:

  • All the medicines that you take (over-the counter and prescription drugs).
  • Any dietary supplements that you take.
  • Any symptoms that you have after eating certain foods.

Have your medicines put in large bottles that are easy to open. – Make sure the labels are easy to read.

for more information – Food and Drug Administration (FDA)
Medications and Older People Website: 

Special Nutrition Needs of Older Adults

dietary supplements

Vitamin and Mineral Supplements

Ideally, people should be able to meet their nutrient needs from food sources alone. However, older adults may find it challenging to obtain enough vitamins and minerals from their diets, especially during illness and other times of low food intake.

A daily multivitamin-mineral supplement can be one way to help older adults meet their nutrient needs. However, they should first consult a physician to be sure that supplements are appropriate for them. The decision to use supplements should be based on their unique needs and dietary intake. It should not be a substitute for proper eating habits or seeking appropriate medical care.

Deceptive advertising and the large variety of supplements on the market may lead older adults to buy supplements that are unnecessary or in potentially harmful doses. Taking high amounts of some nutrients (such as vitamin A, iron, and zinc) can lead to toxic levels in their bodies. Low-dose supplements are less likely to have adverse side effects.

Herbal Supplements

Herbal supplement use has grown dramatically in recent years. Examples are gingko biloba, ginseng, St. John’s wort, and Echinacea. The health claims for these supplements may make them particularly appealing to older adults. However, the jury is still out on their effectiveness. Some studies have shown potential benefits, while others have shown no demonstrable results. Currently, large-scale studies are underway to further test their effectiveness. Until the results are in, it may be too soon to justify any recommendations.

As with medicines, herbal supplements can have potentially harmful side effects. Some can also interact with certain drugs or nutrients. Therefore, older adults should always discuss any current or planned supplement use with their health care providers.

Supplement Health Claim Possible Harmful Effects
Ginkgo Biloba Enhanced memory Improved circulation Antioxidant function Gastrointestinal disturbances Headaches, allergic skin reactions Interactions with anticonvulsants Bleeding if combined with certain medications
Ginseng  Enhanced memory Increased energy Interactions with medications
(Coumadin, Digoxin, MAO inhibitors)
St. John’s wort  Enhanced mood Reduced depression Improved sleep Interactions with medications
(Coumadin, Mevacor, cancer drugs, anticonvulsants, immunosuppressants) Sensitivity to sunlight
Echinacea Enhanced immunity Cold & flu protection Not for use in autoimmune or systemic diseases (lupus, scleroderma, HIV, multiple sclerosis, tuberculosis)
Source: Nutrition and Aging – Herbal Supplements. Facts for Professionals. Pennsylvania State University Nutrition and Extension Partnership Project, 2001

Special Nutrition Needs of Older Adults

barriers to healthy eating

Poor appetite can be common in older adults.  Possible causes include:

  • Grief or bereavement.
  • Fewer social contacts for meals.
  • Acute or chronic illness.
  • Sensory changes (vision, taste, or smell).
  • Medicines that affect appetite.

Tips to help older adults with a poor appetite:

  • Offer beverages that increase calorie or nutrient intake, such as milk, soup, or hot chocolate, in place of coffee and tea. 
  • Enhance the flavor of meals with spices and herbs.
  • Add variety and color to meals.
  • Encourage them to eat smaller meals more frequently, instead of large meals.
  • Make eating a special occasion. Create a positive atmosphere for dining that includes attractive lighting, tablecloths, a nice table setting, and appealing music.
  • Make eating a social occasion. Create special “events” with themes that participants will enjoy together as a group.

Dental Problems

Chewing problems may cause older adults to overly restrict foods important for proper health.  Poorly fitting dentures and missing teeth may cause older people to avoid fresh fruits and vegetables, which are important sources of vitamins, minerals and fiber. 

To promote dental health:

  • Serve foods rich in calcium and phosphorus.
  • Serve a variety of firm, fibrous foods to stimulate the release of saliva.
  • Encourage or provide opportunities for brushing and flossing teeth daily.
  • Encourage older adults to brush their teeth or rinse their mouths with water after meals.
  • Encourage regular visits to the dentist.

To address chewing difficulties in older adults:

  • Offer plenty of water or fluids with meals.
  • Offer foods that are soft and easy to chew.
  • Tender cuts of meat
  • Soft protein foods: eggs, milk, cheese, yogurt
  • Fruits and vegetables with peels removed
  • Fruit juices, canned fruits, and cooked vegetables
  • Cooked cereals, rice, or pasta
  • Mashed or pureed food, if needed

Swallowing Problems

Swallowing is a complex act. It involves the mouth, throat area, and esophagus, which in turn are controlled by many nerves and muscles. Swallowing is partly under conscious control. However, most of the swallowing process is involuntary.

Someone with difficulty swallowing has the sensation that food is stuck in the throat or upper chest. This sensation may be felt high in the neck, or lower down, behind the breastbone (sternum). It may result from problems that arise in chewing food, moving it to the back of the mouth, or moving it through the esophagus toward the stomach.

Common causes of swallowing problems in the mouth or pharynx:

  • Something that blocks the passage of food or liquid. Examples are anxiety, a tumor, or cervical spine disease.
  • Nerve and muscle problems resulting from stroke, Parkinson’s disease, Huntington’s disease, multiple sclerosis, myasthenia gravis, ALS (Lou Gehrig’s disease), muscular dystrophy, polio, or syphilis.

Common causes of swallowing problems in the esophagus:

  • Something that blocks the passage of food. Examples are tumors, foreign bodies, or a narrowed esophagus caused by radiation, medication, or ulcers.
  • Nerve and muscle problems resulting from certain diseases.

To address swallowing problems in older adults:

  • Chop foods in the blender.
  • Avoid dry, chunky foods. Choose foods with a smooth texture.
  • Add cream, gravy, or oil to foods.
  • Avoid serving hot or cold foods.
  • Avoid serving sticky foods.
  • Encourage older adults to rinse their mouths before and after eating.
  • Encourage them to eat in small bites, and to chew food well.
  • Refer them to their health care provider if the problem continues, even if the symptoms are intermittent.
  • If they suddenly show signs of choking and breathing problems, perform the Heimlich maneuver immediately.

Source: Medline Plus Medical Encyclopedia: Swallowing Difficulty, website

Sensory Impairments

As people get older, they become more likely to have sensory impairments(losses in vision, hearing, smell, or taste). These impairments can limit their quality of life, and affect their appetite and interest in foods.

Impaired vision can result from age-related eye changes or from diseases that affect the eyes (cataracts, glaucoma, diabetes, or macular degeneration). Vision may become less sharp. Older adults may find it harder to judge distances, focus on objects at different distances, or see items on the outside edges of the visual field. Their eyes may need stronger light to recognize objects, along with more contrast between light and dark objects. They may find it hard to read recipes, food labels, and labels on medicines.

Hearing problems can result from changes in the inner ear or from tinnitus (ringing or roaring sounds). Older adults may be less able to understand conversations or hear announcements, particularly in noisy or crowded environments. They may withdraw from social interactions with others at group meals.

A reduced ability to smell or taste can make it harder to discriminate between fine tastes, such as between turkey and chicken. Older adults may find it harder to distinguish between sweet, sour, and salty flavors. This can make them lose their appetite or their interest in food, and reduce their ability to detect bad odors in spoiled foods.

Tips for serving meals to adults with sensory impairments:

  • Create a positive atmosphere for dining that includes attractive lighting, tablecloths, a nice table setting, and appealing music.
  • Minimize distractive noises such as televisions and radios.
  • Provide a strong contrast in color (such as cream of wheat in a dark bowl).
  • Provide easy-to-grasp glasses and utensils.
  • Enhance the flavor of meals with spices and herbs.
  • Marinate meats in fruit juices, salad dressing, or sweet-and-sour sauce for extra zest.
  • Use colorful garnishes to make foods more appetizing.
  • Add variety and color to meals.

Sources: (1) Desai M et al. Trends in Vision and Hearing among Older Americans. Aging Trends,March 2001. Centers for Disease Control and Prevention. (2) Institute on Aging Learning Modules, University of North Carolina, website

Cognitive Impairments

Cognitive impairments in older adults can range from minor memory loss to progressive dementia. Causes may include stroke, Alzheimer’s disease, neurological disorders, nutritional deficiencies, or the side effects of taking medicines. As a result, these adults may have a diminished attention span, an increased risk of choking, an inability to recognize thirst, an inability to recognize food, confusion about meal times, and confusion about how to use utensils.

Tips for serving meals to adults with cognitive impairment:

  • Serve meals in small dining rooms with a home-like atmosphere.
  • Provide meals and snacks at consistent times.
  • Provide a consistent seating arrangement to offer structure and cues to mealtimes.
  • Seat people next to compatible tablemates to reduce agitation.
  • Provide adequate lighting to help them recognize foods.
  • Minimize distractive noises such as televisions and radios.
  • Use square place mats to help define personal territory and reduce the chances for people taking each other’s silverware by mistake.
  • Use plain tablecloths and place mats to minimize distractions.
  • Provide a strong contrast in color (such as cream of wheat in a dark bowl).
  • Provide easy-to-grasp glasses and utensils.
  • Model the use of utensils to encourage others to mimic your behavior. Use verbal cues (“place the fork in your hand”) if necessary.
  • Remove utensils if using them becomes dangerous.
  • Put foods on small bowls or plates, and serve them one at a time.
  • Serve small portions of tasty foods that are spiced to their liking.
  • Offer some finger foods unless there is a risk of choking. Examples are mini-sandwiches and bite-size chunks of fruits, vegetables, or cheese.
  • To minimize the risk of choking, avoid hard-cooked eggs, chunks of meat, nuts, whole grapes, orange halves, popcorn, and hard candy. Remove any pits, peels, or bones from foods. Serve raw carrots in long slices. Dilute peanut butter with applesauce.
  • If they fail to recognize foods, encourage them to touch or smell the foods first. Feed them orally by hand if necessary.
  • Provide fluids on a routine basis (at least every 2 hours).

If these tips prove unsuccessful in encouraging food intake, refer older adults’ caregivers to their health care providers.

NUTR 308 – Nutrition for the Older Adult

Worksheet #2 – Identifying Nutritional Concern

Using the DETERMINE nutrition evaluation form, evaluate the nutritional status of an elderly individual from the YMCA senior center.    

Your Name _____________________________________________

Name of Individual Evaluated ______________________________

Senior Center Site ________________________________________

  1. Calculate their BMI and calorie needs using the Mifflin St. Jour formula. Don’t forget to include the Activity Factor (AF)
  • For the individual selected, obtain a list of current medications and supplements taken (prescription and over the counter) 
  • Identify weight history – 
  1. Current weight _________
  • Weight 6 months ago_________
  • Weight 1 year ago___________
  • Weight 5 years ago ____________
  • Weight 10 years ago____________

Percent weight change over the past year (current weight / weight from one year ago)

  • Identify current dental condition, do they have their own teeth, dentures, good or bad condition – no teeth?
  • Do they live alone, if they do not live alone, who else lives in the house – any animals?
  • Who does the primary shopping for food and cooking – how many times a week do they eat away from home and is it at a senior meal site or a restaurant?
  • Do you believe that their calorie intake is meeting their estimated needs – why or why not?
  • From the list of medications, what med/ food interactions might they have – any concerns with current medications?
  • Do they consume alcohol, if so, how much and how often?
  1. What recommendation do you have for this individual?