Geriatric Nursing and Nutritional Issues
What is Nutritional Status
Nutritional status is the balance of nutrient intake, physiological
demands, and metabolic rate (DiMaria- Ghalili , 2002). However, older adults
are at risk for poor nutrition (DiMaria- Ghalili &Amella , 2005).
Furthermore, malnutrition, a recognized geriatric syndrome (Institute of
Medicine [IOM], 2008), is of concern because it can often be unrecognizable and
impacts morbidity, mortality, and quality of life (Chen, Schilling. & Lyder
, 2001) , and is a precursor for frailty in the older adult.
Malnutrition in
older adults is defined as “faulty or inadequate nutritional status;
undernourishment characterized by insufficient dietary intake, poor appetite,
muscle wasting, and weight loss” (Chen et al., 2001). In the older adult,
malnutrition exists along the continuum of care (Furman, 2006).
Older adults
admitted to acute care settings from either the community or long-term care
settings may already be malnourished or may be at risk for the development of malnutrition
during hospitalization.
A diagnosis of malnutrition during an acute care stay
increases the cost of hospitalization estimated at US$1,726 per patient (Rowell
& Jackson, 2010). Bed rest is common during hospital stay, and the
associated loss of lean mass that accompanies bed rest can impact the already
vulnerable nutritional status of older adults (English &Paddon -Jones,
2010).
Nutritional Problems
The prevalence rate of malnutrition in hospitalized older adults
was 38.7% according to a recent pooled analysis of studies based on the
Mini-Nutritional Assessment tool (MNA; Kaiser et al, 2010). In the same study,
47.3% of older adults were at risk for malnutrition (Kaiser et al, 2010).
In
addition, a 1-day international audit on nutrition in 16,455 hospitalized
patients (median age, 66) found that more than half of the patients did not eat
their full meal provided, and decreased food intake was associated with
increased risk of dying ( Hiesmayr et al., 2006).
Preliminary findings from the
first US national nutrition day in 2009 echo these results with 40% of
hospitalized patients eating half or less of their meal (Nutrition Day in the
US, 2011). Marasmus, kwashiorkor, and mixed marasmus-kwashiorkor originally
described the subtypes of malnutrition associated with famine, and these terms
eventually characterized disease- related malnutrition.
An international
guideline committee was organized to develop a consensus approach to defining
adult (including older adults) malnutrition in clinical settings (Jensen et
al., 2010).
Inflammation is the cornerstone of the new adult disease-related
malnutrition subtypes and include “starvation-related malnutrition” (without
inflammation), “chronic disease-related malnutrition” (with chronic
inflammation of a mild-to-moderate degree; eg, rheumatoid arthritis ), and
“acute disease or injury-related malnutrition” (with acute inflammation of a
severe degree; eg, major infections or trauma: Jensen et al., 2010).
Defining
characteristics of this new diagnostic classification of disease-related
malnutrition are under development. The new malnutrition categories underscore
the impact of a loss of lean body mass and skeletal muscle associated with the
catabolic nature of the inflammatory process (Jensen et al., 2010).
Although
sarcopenia is an age-related loss of muscle mass and muscle strength (Rolland,
Van Kan, Gillette- Guyonnet , &Vellas , 2010), bed rest during
hospitalization is also associated with a loss of lean body mass, which
adversely impacts functional capacity (Rowell & Jackson, 2010).
The risk factors for malnutrition in the older adult are multifactorial
and include dietary, economic, psychosocial, and physiological factors
(DiMaria- Ghalili &Amella , 2005). Dietary factors include little or no
appetite (Carlsson, Tidermark , Ponzer , Söderqvist , & Cederholm, 2005;
Reuben, Hirsch, Zhou, & Greendale, 2005; Saletti et al., 2005).
Pproblems
with eating or swallowing, eating inadequate servings of nutrients (Margetts,
Thompson, Elia, & Jackson, 2003), and caring fewer than two meals a day (
Saletti et al., 2005).
Limited income may cause restriction in the number of
meals caten per day or dietary quality of meals eaten (Souter & Keller,
2002). Isolation is also a risk factor as older adults who live alone may lose
their desire to cook because of loneliness, and appetite often decreases after
the loss of a spouse (Shahar, Schultz, Shahar, & Wing, 2001).
Impairment in
functional status can place the older adult at risk for malnutrition (Oliveira,
Fogaca , & Leandro-Merhi, 2009) since adequate functioning is needed to
secure and prepare food (Sharkey, 2008). Difficulty in cooking is related to
disabilities (Souter et al., 2002), and disabilities can prevent the ability to
prepare or ingest food ( Saletti et al., 2005).
Chronic conditions can
negatively influence nutritional intake as well as cognitive impairment (
Kagansky et al., 2005). Psychological factors are known risk factors of
malnutrition. For example, depression is related to unintentional weight loss
(Morley, 2001; Thomas et al., 2002).
Furthermore, poor oral health ( Saletti et
al., 2005) and xerostomia (dry mouth caused by decreased saliva) can impair the
ability to lubricate, masticate, and swallow food ( Saletti et al., 2005).
Antidepressants, antihypertensives, and bronchodilators can contribute to
xerostomia (DiMaria- Ghalili &Amella , 2005). Change in taste (from
medications, nutrient deficiencies, or taste bud atrophy) can also alter
nutritional intake (DiMaria- Ghalili & Amelia, 2005).
Body composition changes in normal aging include increase in body
fat, including visceral fat stores (Hughes et al., 2004) and a decrease in lean
body mass (Janssen , Heymsfield , Allison, Kotler, & Ross, 2002).
Furthermore, the low skeletal muscle mass associated with aging is related to
functional impairment and physical disability (Janssen I, Heymsfield , &
Ross, 2002).
The impact of malnutrition on the health of the hospitalized older
adult is well documented. In this population, malnutrition is related to
prolonged hospital stay ( Pichard et al., 2004), increased risk of poor health
status, recent hospitalization, and institutionalization (Margetts et al.,
2003). Additionally, low MNA scores are predictors of prolonged hospital stays
and mortality (Sharkey, 2008).
Assessment of Nutritional Status
Areas of nutrition status assessment in the hospitalized older adult
should focus on identification of malnutrition and risk factors for
malnutrition. The MNA ( Guigoz , Lauque , &Vellas , 2002) is a
comprehensive two-level tool that can be used to screen and assess the older
hospitalized patient for malnutrition by evaluating the presence of risk
factors for malnutrition in this age group (DiMaria- Ghalili & Guenter,
2008).
The validity and reliability of the MNA for use in hospitalized older
adults is well documented (Salva et al., 2004). If a patient scores less than
12 on the screen, then the assessment section should be completed in order to
compute the malnutrition indicator score.
The screening section of the MNA is
easy to administer and is comprised of six questions. The assessment section
requires measurement of midarm muscle circumference and calf circumference.
Although these anthropometric measurements are relatively easy to obtain with a
tape measure, nurses may first require training in these procedures prior to
incorporating the MNA as part of a routine nursing assessment. Protocols should
be established to identify interventions to be implemented once the screening
and assessment data are obtained and should include consultation with a
dietitian.
See http:// consultgerirn.org/resources for Assessing Nutrition in
Older Adults (Portable document Form [PDF] file) for MNA In Nutrition topic and
Resources section.
Additional assessment strategies include proper measurement of
height and weight and a detailed weight history. Height should always be
measured directly and never recorded via patient self-report. An alternative
way to measuring standing height is knee height (Salva et al., 2004) with
special calipers.
An alternative to knee height measures is a demi-span
measurement, half the total arm span. (For directions on estimating height
based on demi-span measurement, see Appendix 2 in A Guide to Completing the
Mini Nutritional Assessment at http://www .mna-elderly.com/mnaguide.pdf).
A
calorie count or dietary intake analysis is a good way to quantify the type and
amount of nutrients ingested during hospitalization (DiMaria- Ghalili
&Amella , 2005). Laboratory indicators of nutritional status include
measures of visceral proteins such as serum albumin, transferrin, and
prealbumin (DiMaria- Ghalili &Amella , 2005).
However, these visceral
proteins are also negative acute phase reactants and are decreased during a
stressed inflammatory state, limiting the ability to predict malnutrition in
the acutely ill hospitalized patient. In spite of this, albumin is a strong prognostic
marker for morbidity and mortality in the older hospitalized.
Patient (Sullivan
et al., 2005). As biomarkers of inflammation are translated from research to
clinical practice, future nutritional assessment protocols will incorporate
inflammatory markers.
Interventions and Care Strategies
The nursing interventions outlined in the protocol focus on
enhancing or promoting nutritional intake and range in complexity from basic
fundamental nursing care strategies to the administration of artificial nutrition
via parenteral or enteral routes.
Prior to initiating targeted nutritional
interventions in the hospitalized older adult, it must first be determined if
the older adult cannot eat, should not cat, or will not eat (American Society
for Parenteral and Enteral Nutrition [ASPEN], 2002).
Factors to consider
include the gastrointestinal tract (starting with the mouth) working properly
without any functional, mechanical, or physiological alterations that would
limit the ability to adequately ingest, digest, and/or absorb food.
Also, does
the older adult have any chronic or acute health condition in which the normal
intake of food is contraindicated? Or, is the older adult simply not eating, or
is the appetite decreased? If the gastrointestinal tract is functional and can
be used to provide nutrients then nutritional interventions should be targeted
at promoting adequate oral intake.
Nursing care strategies focus on ways to increase food intake as
well as ways to enhance and manage the environment to promote increased food
intake.
When functional or mechanical factors limit the ability to take in
nutrients, nurses should obtain interdisciplinary consultations from speech
therapists, occupational therapists, physical therapists, psychiatrists, and/or
dietitians to collaborate on strategies that would enhance the ability of the
older adult to feed themselves or to cat.
Oral nutritional supplementation has
been shown to improve nutritional status in malnourished hospitalized older
adults (Capra et al., 2007) and should be considered in the hospitalized older
adult who is malnourished or is at risk for malnutrition.
When used, oral
liquid nutritional supplements should be given at least 60 minutes prior to
meals (Wilson et al., 2002). Specialized nutritional support should be reserved
for select situations. If the provision of nutrients via the gastrointestinal
tract is contraindicated, then parental nutrition via the central or peripheral
route should be initiated (ASPEN, 2002).
If the gastrointestinal tract can be utilized,
then nutrients should be delivered via enteral tube feeding (ASPEN, 2002). The
exact location of the tube and type of feeding tube inserted depends on the
disease state, length of time tube feeding is required, and risk of aspiration.
Patients started on specialized nutritional support should be routinely
reassessed for the continued need for specialized nutritional support and
transitioned to oral feeding when feasible. Also, advance directives, if not
completed, should be addressed prior to initiating specialized nutrition
support (see Chapters 28 and 29, Health Care Decision Making and Advance
Directives).