Malnutrition
Julie Adkins, Jill C. Cash, Beverly R. Byram, Cheryl A. Glass, Kristin Ownby, and Pat Obulaney
Definition
A.Malnutrition refers to deficiencies, excesses, or imbalances in a person’s intake of energy and/or nutrients. The term malnutrition
covers two broad groups of conditions (WHO, 2016).
B.The term undernutrition applies to individuals who lack the calories, protein, or other nutrients needed for tissue maintenance and repair. Identification and treatment of adult undernutrition is a major concern in acute, chronic, and transition care settings.
C.A malnourished state is defined as any of the following:1
1.Body mass index (BMI) less than 18.5 kg/m2.
2.Unintentional weight loss greater than 10% within the last 3 to 6 months.
3.BMI less than 20 kg/m2 and unintentional weight loss greater than 5% within the last 3 to 6 months.
D.Obesity:
1.BMI 25 to 30 is considered overweight.
2.BMI greater than 30 is considered to be obese.
Incidence
A.Depending on the patient population and criteria used to identify malnutrition, estimates of adult malnutrition range from 15% to 60%. 10% to 30% of geriatrics living in the community suffer from malnutrition. Prevalence rises to as high as 85% when an elderly person lives in a long-term care facility. For elderly patients in acute care, malnutrition rates reach 70%.
B.Sarcopenia prevalence ranges from 1% to 29% in the community dwelling elderly and 14% to 33% for persons who reside in a long-term care facility. Chronic illnesses and disabilities increase the risk.
Pathogenesis
A.Primary protein-energy malnutrition. arises from insufficient dietary intake, or intake of protein of poor enough quality to make availability of essential amino acids a limiting factor in the support of metabolism.
B.Secondary protein-energy malnutrition arises when illness or other factors impair the uptake or utilization of nutrients, increase protein or energy requirements, or increase metabolic losses beyond nutrient availability.
Predisposing Factors
A.Patients 65 years of age or older.
B.Patients living in a nursing or care home.
C.Patients admitted to the hospital.
D.Patients who abuse drugs or alcohol.
E.Patients with malabsorption syndromes.
F.Poverty.
G.Comorbidities:
1.Chronic obstructive pulmonary disease (COPD).
2.Coronary artery heart disease.
3.Cancer.
4.Depression.
5.Dementia.
6.Cerebrovascular accident.
7.Arthritis.
8.Chronic or end-stage renal disease.
9.Diabetes mellitus.
Common Complaints
A.Losing weight without trying.
B.Decreased appetite.
C.Difficulty eating.
D.Fatigue.
E.Difficulty concentrating.
F.Feeling cold.
G.Longer healing time for wounds.
H.Depressed mood.
I.Activity intolerance.
J.Difficulty with food procurement and preparation.
Other Signs and Symptoms
A.Decreased libido.
B.Dry skin; dry, sparse, brittle hair.
C.Breathing difficulties.
D.Ankle swelling.
Subjective Data
A.Weight loss or gain in past 6 months. Was weight loss intentional? (Unintentional loss of more than 10% of normal body weight in last 3–6 months is of concern.)
B.Changes in dietary intake.
C.Gastrointestinal symptoms including nausea, diarrhea, constipation, flatulence, pain, dysphagia, xerostomia, appetite changes.
D.Dental problems including dentures.
E.Changes in vision, smell, or taste.
F.Medications taken including prescribed and over-the-counter (OTC):
1.Medications that can lead to anorexia in the older patient include the following:
a.Amiodorone.
b.Furosemide.
c.Digoxin.
d.Spironolactone.
e.Levodopa.
f.Fluoxetine.
g.H2 antagonists.
h.proton pump inhibitors (PPIs).
i.Nonsteroidal anti-inflammatory drugs (NSAIDs).
G.Changes to skin, hair, conjunctiva, or buccal mucosa; delayed wound healing.
H.Place of residence:
1.Exposure to food contamination.
2.Toxins.
3.Readily access to groceries.
I.Fatigue, shortness of breath, muscle cramps.
J.Comorbidities (see list under risk factors).
K.Functional capacity:
1.Does the patient have trouble carrying out activities of daily living (ADLs)?
2.Can they shop and prepare food?
L.Disease and its relation to nutrition requirements.
M.Women of childbearing age—menstrual cycle irregularities.
N.History of eating disorders.
O.Cultural and religious practices.
P.Dietary history:
1.Daily dietary intake and preferences.
2.Past dietary history.
3.Alcohol consumption.
4.Food allergies and intolerances.
Physical Examination
A.Measurement of weight and height, and proportions; compare to standards of age and gender.
B.Calculate BMI.
C.Body measurements:
1.Measurement of waist circumference.
2.Measure muscle mass by measuring calf and mid-arm circumferences.
3.Evaluate muscle strength using a dynamometer to determine handgrip strength.
D.Inspect:
1.Body fat distribution.
2.Inspect oral cavity including teeth and if patient has dentures, determine their fit. Note changes to the integrity of the tongue, gingiva, lips, and oral mucosa can indicate a vitamin deficiency; oral candidiasis.
3.Inspect skin and hair looking for dryness, fragility, flakiness, or discoloration of skin.
4.Look for hair that is brittle, thin, and easy to pull out.
E.Palpate:
1.Ankle and sacral edema, which may indicate protein imbalances.
2.Thyroid gland for enlargement of nodules.
F.Assess neurological changes:
1.Central and peripheral visual acuity.
2.Assess cognitive function using a validated tool.
3.Examine vibratory sense with tuning fork if B12 deficiency suspected.
4.Screen for visual acuity and hearing annually.
Diagnostic Tests
A.Complete metabolic panel, complete blood count (CBC), thyroid-stimulating hormone (TSH).
B.Vitamins A, B2, B6, B12, niacin, C, D, E, K, thiamine.
C.Minerals including zinc, iron (iron level, total iron-binding capacity (TIBC), ferritin), iodine.
D.C-reactive protein (CRP) if inflammatory process suspected.
E.Dual-energy x-ray absorptiometry (DEXA) scan.
F.Swallow evaluation if indicated.
G.Celiac serology if indicated.
H.Stool for ova and parasites if indicated.
I.Screen with valid nutrition screening tool such as Mini Nutritional Assessment (MNA) or Malnutrition Universal Screening Tool (MUST).
Recent analysis indicates albumin and prealbumin are no longer considered reliable markers of nutrition.
Differential Diagnoses
A.Starvation-related malnutrition:
1.Anorexia nervosa and bulimia.
2.Chronic starvation.
B.Chronic disease–related malnutrition:
1.End-stage renal disease.
2.Chronic pancreatitis.
3.Cancers.
4.Cardiovascular disease (CVD).
5.Sarcopenia
6.Rheumatoid arthritis.
7.Obesity.
8.Malabsorption syndromes including celiac disease.
9.HIV/AIDS.
10.Chronic respiratory disease including COPD, cystic fibrosis.
C.Acute disease or injury-related malnutrition:
1.Major infections.
2.Burns.
3.Acute pancreatitis.
Plan
A.General interventions:
1.Address underlying etiology.
2.Interdisciplinary approach to problem including pneumocystis pneumonia (PCP), dietician, social worker, occupational and/or physical therapist, nursing.
3.Social support and referrals to food pantries and food delivery services (i.e., Meals on Wheels) and coordination of nutritional services.
4.Physical therapy and/or occupational therapy to evaluate and address functional status deficiencies:
a.Progressive resistance training two to three times a week helps to increase muscle strength and improve function especially with sarcopenia.
5.Nursing care for dietary and weight monitoring.
B.Patient teaching:
1.Dietary education including food preparation:
a.Food first approach:
i.Three small meals with snacks in between every day (add foods such as oil, butter, cheese, cream, sauces to meals and snacks to boost energy intake).
ii.Choose nourishing fluids such as milky drinks, soups, fruit juice.
iii.Add foods dense in protein and calories such as powdered milk.
iv.Reassess weight in 4 weeks.
v.Oral nutritional supplementation can be added. Usually accounts for 300 to 400 kcal/d.
2.Vitamin and/or mineral supplementation as indicated per lab results.
C.Pharmaceutical therapy:
1.Dronabinol (Marinol).
2.Megestrol (Megace).
3.Testosterone.
4.Herbal products:
a.Dandelion.
b.Chamomile.
Follow-Up
A.Check weight in 4 weeks. If no improvement, refer for enteral or parenteral nutrition support
Consultation/Referral
A.Refer to psych/mental health services for eating disorders or clinical depression.
B.Refer to gastroenterology for endoscopy.
C.Refer to gerontologist if failure to improve.
D.Refer to registered dietician, physical therapy, or occupational therapy.
Individual Considerations
A.Geriatrics:
1.After any acute event or illness, rescreen patient for malnutrition.
2.Assess for malnutrition annually in patients who reside in a community dwelling.
3.Assess every 3 months in patients who reside in an institutional facility.