Rose Ann DiMaria-Ghalili
EDUCATIONAL OBJECTIVES
On completion of this chapter, the reader should be able to:
1. Recognize factors that place the older adult at risk for malnutrition
2. Discuss methods to screen and assess nutritional status in the older adult
3. Use appropriate nursing interventions in the hospitalized older adult who is either at risk for malnutrition or has malnutrition
4. Identify the importance of screening for nutrition risk during transitions in care
OVERVIEW
Nutritional status is the balance of nutrient intake, physiological demands, and metabolic rate (DiMaria-Ghalili, 2002). However, older adults are at risk of 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, p. 139). 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 length of stay (12.6 ± 5 vs. 4.4 ±1 days), cost of hospitalization ($26,944 vs. $9,485), and services needed on discharge (e.g., home care, long-term care; Corkins et al., 2014). 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). The IOM notes that although malnutrition is a problem in older adults, most health care professionals, including nurses, have little training concerning the nutritional needs of older adults (IOM, 2008). Therefore, it is imperative that acute care nurses carefully assess and monitor the nutritional status of older adults to identify the risk factors of malnutrition so that appropriate interventions are instituted in a timely fashion. The focus of this nursing protocol is the discussion of nutrition in aging as it relates to risk factors, implications, and interventions for malnutrition in the older adults.
BACKGROUND AND STATEMENT OF PROBLEM
The prevalence of malnutrition in older adults varies across studies and settings. Using a large probability sample of community-dwelling older adults (60 years and older), 5.9% were malnourished and 56.3% were at risk of malnutrition (DiMaria-Ghalili, Michael, & Rosso, 2013). Researchers report the prevalence of malnutrition in older adults in nursing homes between 1.5% and 67% (Bell, Lee, & Tamura, 2015) and between 12% and 70% in hospitals (Heersink, Brown, DiMaria-Ghalili, & Locher, 2010). Limited information is currently available on the prevalence of malnutrition as older adults transition from the hospital to the home. However, older adults do experience declines in nutrition and health status after hospital discharge, which impact the ability to shop and prepare meals, placing them at further nutritional risk after discharge from the hospital (Anyanwu, Sharkey, Jackson, & Sahyoun, 2011).
Marasmus, kwashiorkor, and mixed marasmus–kwashiorkor originally described the subtypes of malnutrition associated with famine, and these terms eventually characterized disease-related malnutrition. In 2012, the Academy of Nutrition and Dietetics and the American Society for Parenteral and Enteral Nutrition published criteria for the identification of adult malnutrition (undernutrition; White et al., 2012). Inflammation is the cornerstone of the new adult disease-related malnutrition subtypes and include “starvation-related malnutrition” in the context of social and environmental circumstances (without inflammation), “chronic disease-related malnutrition” (with chronic inflammation of a mild to moderate degree; e.g., rheumatoid arthritis), and “acute disease or injury-related malnutrition” (with acute inflammation of a severe degree; e.g., major infections or trauma). Defining characteristics focus on energy intake, weight loss, physical findings (loss of body fat, muscle mass, and presence of fluid accumulation), and reduced grip strength. Visceral proteins (e.g., albumin, prealbumin) are negative acute phase proteins, typically suppressed during an inflammatory state, and are not indicative of nutritional status during inflammation. Consequently, albumin is no longer recommended to identify malnutrition (White et al., 2012). The new adult 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, 2011), 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), problems with eating or swallowing (Serra-Prat et al., 2012), eating inadequate servings of nutrients, and eating fewer than two meals a day (Ramic et al., 2011). Limited income may cause restriction in the number of meals eaten per day or dietary quality of meals eaten (Lee & Berthelot, 2010; Samuel et al., 2012). 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 (Ramic et al., 2011; Stroebe, Schut, & Stroebe, 2007). Impairment in functional status can place the older adult at risk of malnutrition (Oliveira, Fogaca, & Leandro-Merhi, 2009) because adequate functioning is needed to secure and prepare food (DiMaria-Ghalili, 2014). Difficulty in cooking is related to disabilities, and disabilities can hinder the ability to prepare or ingest food (Anyanwu et al., 2011; DiMaria-Ghalili, 2014). Chronic conditions can negatively influence nutritional intake as well as cognitive impairment (Inelmen, Sergi, Coin, Girardi, & Manzato, 2010). Psychological factors are known risk factors of malnutrition. For example, depression is related to unintentional weight loss (Chen, Baik, Huang, & Tang, 2007; Engel et al., 2011). Furthermore, poor oral health (Palacios & Joshipuro, 2015) and xerostomia (dry mouth caused by decreased saliva) can impair the ability to lubricate, masticate, and swallow food (Palacios & Joshipuro, 2015). 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 & Amella, 2005).
Body composition changes in normal aging include increase in body fat, visceral fat stores, 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, 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, poor health status, institutionalization, and death (Corkins et al., 2014). Malnutrition is also related to frailty and impaired functional status (Litchford, 2014).
ASSESSMENT OF THE PROBLEM
Areas of nutrition status assessment in the hospitalized older adult should focus on identification of malnutrition and risk factors for malnutrition not only during hospitalization, but also on hospital discharge. The Joint Commission mandates a nutrition screening be performed within 24 hours of hospital admission for all patients (The Joint Commission, 2009). In a recent survey of nurses’ nutrition screening and assessment practices (n = 545), nurses reported they are primarily responsible for the initial nutrition screening (Guenter & DiMaria-Ghalili, 2013). Thirty-one percent reported using a validated nutrition assessment tool, the most frequently reported were the Mini-Nutritional Assessment (MNA; 49.1%) and the Subjective Global Assessment (32.4%).
The MNA (Guigoz, Vellas, & Garry, 1994) 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 MNA-SF (short form) is based on the full MNA, the original 18-item questionnaire. The MNA-SF consists of six questions on food intake, weight loss, mobility, psychological stress or acute disease, presence of dementia or depression, and body mass index (BMI; Kaiser et al., 2010), and can be used as a screening tool. The full MNA provides a more detailed assessment. The validity and reliability of the MNA for use in hospitalized older adults is well documented (Salva, Corman, Andrieu, Salas, Porras, & Vellas, 2004). If a patient scores less than 12 on the screen (MNA-SF), then the assessment section should be completed in order to compute the malnutrition indicator score. The MNA-SF is easy to administer and is comprised of six questions. The assessment section requires measurement of midarm muscle and calf circumference. Although these anthropometric measurements are relatively easy to obtain with a tape measure, nurses may first require training in these procedures before 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 “Nutrition in the Elderly” in the Resources section for the topic of MNA in nutrition and consultgerirn.org/resources for Assessing Nutrition in Older Adults (DiMaria-Ghalili & Amella, 2012).
Additional assessment strategies include proper measurement of height and weight and a detailed weight history. Height should always be directly measured and never recorded via patient self-report. An alternative way of measuring standing height is knee height (Salva et al., 2004) with special calipers. An alternative to knee height measures is a demispan measurement, meaning 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 from the Nestle Nutrition Institute at www.mna-elderly.com/mna_forms.html.)
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). Traditionally, laboratory indicators of nutritional status included 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. Monitoring inflammatory markers, such as C-reactive protein (Jensen, Hsiao, & Wheeler, 2012) or interleukin 6 (Jensen & Wheeler, 2012), can help to determine if depleted albumin reflects malnutrition or an inflammatory response. In spite of this, albumin is a strong prognostic marker for morbidity and mortality in the older hospitalized patient (Sullivan, Roberson, & Bopp, 2005).
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. Before initiating targeted nutritional interventions in the hospitalized older adult, it must first be determined whether the older adult cannot eat, should not eat, or will not eat (Sobotka et al., 2009; Ukleja et al., 2010; Volkert et al., 2006). 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 himself or herself or to eat. Oral nutritional supplementation has been shown to improve nutritional status in malnourished hospitalized older adults (Joanna Briggs Institute, 2007; Volkert et al., 2006) and should be considered in the hospitalized older adult who is malnourished or is at risk of malnutrition. When used, oral liquid nutritional supplements should be given at least 60 minutes before meals (Wilson, Purushothaman, & Morley, 2002). Specialized nutritional support should be reserved for select situations. If the provision of nutrients via the gastrointestinal tract is contraindicated, then parenteral nutrition via the central or peripheral route should be initiated (Ukleja et al., 2010). If the gastrointestinal tract can be used, then nutrients should be delivered via enteral tube feeding (Ukleja et al., 2010). The exact location of the tube and type of feeding tube inserted depend 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 nutrition support and transitioned to oral feeding when feasible. Also, advance directives, if not completed, should be addressed before initiating specialized nutrition support (see Chapter 4, “Health Care Decision Making” and Chapter 39, “Advance Care Planning”).
CASE STUDY
Mrs. V. H. is a 75-year-old female admitted to the hospital with a myocardial infarction and is on a telemetry unit for further workup before coronary artery bypass grafting surgery. On admission, her standing height is 5 feet 8 inches and she weighs 140 pounds. Her BMI is 21.33. Her past medical history is significant for rheumatoid arthritis. She describes herself as generally in good health until she was admitted to the hospital. Medications include 400 mg of ibuprofen every 6 hours, as needed. Mrs. V. H. is the primary caregiver for her 80-year-old husband, who has altered cognitive functioning and is bedridden after a stroke 3 years ago. She complained of being tired and lacking energy before admission. Her weight history is significant for a 10-pound weight loss in the past 3 months. Mrs. V. H. said she started taking oral energy drinks because she was often too tired to cook a complete dinner for herself and lacked energy and was concerned about weight loss. She reported regaining 2 pounds after taking three cans of an oral nutritional supplement per day for about 4 weeks. She reported having more strength after regaining some of her weight back. Although she is married, she is isolated because she does not have any social support systems to rely on. Her only living relative is a cousin who is 70 years old and lives 60 miles away and visits twice a month. During the assessment, Mrs. V. H. continually complained of being physically exhausted from caring for her husband at home and being too tired to eat or cook a nutritious meal for herself. She is worried about how she will care for her husband on discharge from surgery and hopes that she can recover in the same nursing home that her husband was admitted to.
Mrs. V. H. does have chronic inflammatory conditions (rheumatoid arthritis and cardiovascular diseases) that along with the recent weight loss could place her at risk for chronic inflammatory malnutrition. Furthermore, her social history is significant and could contribute to starvation-related malnutrition. As the sole caregiver for her disabled husband, she is isolated, tired, and has a decreased appetite. Her MNA-SF score is 7 based on moderate loss of appetite, weight loss greater than 6.6 pounds during the last 3 months, goes out, has suffered an acute event, has no psychological problems, and has a BMI of 21.33. Because her score is below 11, she is at risk for malnutrition, and a complete assessment level of the MNA is performed. Her total MNA assessment score is 17.5 based on an assessment score of 10.5 and a screening score of 7.0, indicating she is at risk for malnutrition. Although she is on a regular diet, she only takes in about 50% of her meals. Oral nutritional supplements are ordered twice daily between meals. Consultations obtained from the social worker, dietitian, and physical therapist are warranted.
SUMMARY
Hospitalized older adults are at risk of malnutrition. Nurses should carefully assess and monitor the nutritional status of the older hospitalized patient so that appropriate nutrition-related interventions can be implemented in a timely fashion.
NURSING STANDARD OF PRACTICE
Protocol 10.1: Nutrition in Aging
I. GOAL
Improve in indicators of nutritional status in order to optimize functional status and general well-being and promote positive nutritional status
II. OVERVIEW
Older adults are at risk of malnutrition, with 39% to 47% of hospitalized older adults being malnourished or at risk of malnutrition (Kaiser et al., 2010).
III. BACKGROUND/STATEMENT OF PROBLEM
A. Definition(s)
1. Malnutrition: Any disorder of nutritional status, including disorders resulting from a deficiency of nutrient intake, impaired nutrient metabolism, or overnutrition
B. Etiology and/or epidemiology: Older adults are at risk for undernutrition because of dietary, economic, psychosocial, and physiological factors (DiMaria-Ghalili & Amella, 2005).
1. Dietary intake
a. Little or no appetite (Carlsson et al., 2005; Ramic et al., 2011)
b. Problems with eating or swallowing (Serra-Prat et al., 2012)
c. Eating inadequate servings of nutrients (Ramic et al., 2011)
d. Eating fewer than two meals a day (Ramic et al., 2011)
2. Limited income may cause restriction in the number of meals eaten per day or dietary quality of meals eaten (Samuel et al., 2012).
3. Isolation
a. Older adults who live alone may lose desire to cook because of loneliness (Ramic et al., 2011; Stroebe et al., 2007)
b. Appetite of widows decreases (DiGiacomo, Lewis, Lolan, Phillips, & Davidson, 2013)
c. Difficulty cooking because of disabilities (Anyanwu et al., 2011)
d. Lack of access to transportation to buy food (DiMaria-Ghalili & Amella, 2005)
4. Chronic illness
a. Chronic conditions can affect intake (DiMaria-Ghalili, 2014).
b. Disability can hinder ability to prepare or ingest food (Anyanwu et al., 2011; Litchford, 2014).
c. Depression can cause decreased appetite (Engel et al., 2011).
d. Poor oral health (cavities, gum disease, and missing teeth), and xerostomia, or dry mouth impairs ability to lubricate, masticate, and swallow food (Palacios & Joshipura, 2015).
e. Antidepressants, antihypertensives, and bronchodilators can contribute to xerostomia (DiMaria-Ghalili & Amella, 2005).
5. Physiological changes
a. Decrease in lean body mass and redistribution of fat around internal organs lead to decreased caloric requirements (Janssen, Heymsfield, Allison, et al., 2002)
b. Change in taste (from medications, nutrient deficiencies, or taste bud atrophy) can also alter nutritional status (DiMaria-Ghalili & Amella, 2005)
IV. PARAMETERS OF ASSESSMENT
A. General: During routine nursing assessment, any alterations in general assessment parameters that influence intake, absorption, or digestion of nutrients should be further assessed to determine whether the older adult is at nutritional risk. These parameters include:
1. General assessment, including present history, assessment of symptoms, past medical and surgical history, and comorbidities (DiMaria-Ghalili, 2014)
2. Social history (DiMaria-Ghalili, 2014)
3. Drug–nutrient interactions: Drugs can modify the nutrient needs and metabolism of older people. Restrictive diets, malnutrition, changes in eating patterns, alcoholism, and chronic disease with long-term drug treatment are some of the risk factors in older adults that place them at risk for drug–nutrient interactions (DiMaria-Ghalili, 2014).
4. Functional limitations (DiMaria-Ghalili, 2014)
5. Psychological status (DiMaria-Ghalili, 2014)
6. Physical assessment: Physical examination with emphasis on oral examination (see Chapter 8, “Oral Health Care”); loss of subcutaneous fat, muscle wasting, and BMI (DiMaria-Ghalili, 2014); and dysphagia.
B. Dietary intake: In-depth assessment of dietary intake during hospitalization may be documented with a dietary intake analysis (calorie count; DiMaria-Ghalili & Amella, 2005).
C. Risk assessment tool: The MNA should be performed to determine whether an older hospitalized patient is either at risk of malnutrition or has malnutrition. The MNA determines risk based on food intake, mobility, BMI, history of weight loss, psychological stress, or acute disease, and dementia or other psychological conditions. If score on the MNA-SF is 11 points or less, the in-depth MNA assessment should be performed (DiMaria-Ghalili & Guenter, 2008). See the Resources section or go to consultgerirn.org/resources for nutrition information.
D. Anthropometry
1. Obtain an accurate weight and height through direct measurement. Do not rely on patient recall. If the patient cannot stand erect to measure height, then either a demi-span measurement or a knee-height measurement should be taken to estimate height using special knee-height calipers (DiMaria-Ghalili & Amella, 2005). Height should never be estimated or recalled because of shortening of the spine with advanced age; self-reported height may be off by as much as 2.4 cm (DiMaria-Ghalili & Amella, 2005).
2. Weight history: A detailed weight history should be obtained along with current weight. Detailed weight history should include a history of weight loss, whether the weight loss was intentional or unintentional, and during what period. A loss of 10 pounds. over a 6-month period, whether intentional or unintentional, is a critical indicator for further assessment (DiMaria-Ghalili & Amella, 2005).
3. Calculate BMI to determine whether weight for height is within normal range: 23 to 30. A BMI below 23 is a sign of undernutrition (Centers for Medicare & Medicaid Services, 2011).
E. Visceral proteins: Serum albumin, transferrin, and prealbumin are visceral proteins traditionally used to assess and monitor nutritional status (DiMaria-Ghalili & Amella, 2005). However, keep in mind that these proteins are negative acute-phase reactants, so during a stress state, the production is usually decreased. In the older hospitalized patient, albumin levels may be a better indicator of prognosis than nutritional status (White et al., 2012). Consider using inflammatory markers (C-reactive protein or interleukin-6) to ascertain whether the changes in albumin are caused by nutritional alterations or an inflammatory state (Jensen et al., 2012; Jensen & Wheeler, 2012).
F. Functional status: Measure handgrip strength using a hand dynamometer (White et al., 2012); review ability to perform ADL and IADL (DiMaria-Ghalili, 2014).
G. Transitional care needs determine the ability of the patient to shop, cook, and feed self after discharge (DiMaria-Ghalili, 2014).
V. NURSING CARE STRATEGIES
A. Collaboration (DiMaria-Ghalili & Amella, 2005)
1. Refer to a dietitian if the patient is at risk of undernutrition or has undernutrition.
2. Consult with a pharmacist to review the patient’s medications for possible drug–nutrient interactions.
3. Consult with a multidisciplinary team specializing in nutrition.
4. Consult with a social worker, an occupational therapist, and a speech therapist as appropriate.
B. Alleviate dry mouth
1. Avoid caffeine; alcohol and tobacco; and dry, bulk, spicy, salty, or highly acidic foods.
2. If the patient does not have dementia or swallowing difficulties, offer sugarless hard candy or chewing gum to stimulate saliva.
3. Keep lips moist with petroleum jelly.
4. Take frequent sips of water.
C. Maintain adequate nutritional intake
Daily requirements for healthy older adults include 30 kcal/kg of body weight, and 1 to 1.2 g/kg of protein per day (Bauer et al., 2013), with no more than 30% of calories from fat. Caloric, carbohydrate, protein, and fat requirements may differ depending on degree of malnutrition and physiological stress.
D. Improve oral intake
1. Assess each patient’s ability to eat within 24 hours of admission (Jefferies, Johnson, & Ravens, 2011).
2. Engage in mealtime rounds to determine how much food is consumed and whether assistance is needed (Jefferies et al., 2011)
3. Limit staff breaks to before or after patient mealtimes to ensure that adequate staff are available to help with meals (Jefferies et al., 2011).
4. Encourage family members to visit at mealtimes.
5. Ask family to bring favorite foods from home when appropriate.
6. Ask about patient food preferences and honor them.
7. Suggest small, frequent meals with adequate nutrients to help patients regain or maintain weight (Joanne Briggs Institute, 2007).
8. Provide nutritious snacks (Joanne Briggs Institute, 2007).
9. Help patient with mouth care and placement of dentures before food is served (Jefferies et al., 2011).
E. Provide conducive environment for meals
1. Remove bedpans, urinals, and emesis basins from rooms before mealtime.
2. Administer analgesics and antiemetics on a schedule that will diminish the likelihood of pain or nausea during mealtimes.
3. Serve meals to patients in a chair if they can get out of bed and remain seated.
4. Create a more relaxed atmosphere by sitting at the patient’s eye level and making eye contact during feeding.
5. Order a late food tray or keep food warm if the patients are not in their rooms during mealtimes.
6. Do not interrupt patients for round and nonurgent procedures during mealtimes.
F. Specialized nutritional support (Sobotka et al., 2009; Ukleja et al., 2010; Volkert et al., 2006)
1. Start specialized nutritional support when a patient cannot, should not, or will not eat adequately and if the benefits of nutrition outweigh the associated risks.
2. Before initiation of specialized nutritional support, review the patient’s advance directives regarding the use of artificial nutrition and hydration.
G. Provide oral supplements
1. Supplements should not replace meals but should be provided between meals and not within the hour preceding a meal and at bedtime (Joanne Briggs Institute, 2007; Wilson et al., 2002).
2. Ensure that oral supplement is at the appropriate temperature (Joanne Briggs Institute, 2007).
3. Ensure that the patient can open oral supplement packaging (Joanne Briggs Institute, 2007).
4. Monitor the intake of the prescribed supplement (Joanne Briggs Institute, 2007).
5. Promote a sip style of supplement consumption (Joanne Briggs Institute, 2007).
6. Include supplements as part of the medication protocol (Joanne Briggs Institute, 2007).
H. NPO orders
1. Schedule older adults for tests or procedures early in the day to decrease the length of time they are not allowed to eat and drink.
2. If testing late in the day is inevitable, ask the physician whether the patient can have an early breakfast.
3. See ASA practice guideline regarding recommended length of time patients should be kept NPO for elective surgical procedures.
VI. EVALUATION/EXPECTED OUTCOMES
A. Patient will
1. Experience improvement in indicators of nutritional status.
2. Improve functional status and general well-being.
B. Provider should
1. Ensure that care includes food and fluid of adequate quantity and quality in an environment conducive to eating, with appropriate support (e.g., modified eating aids) for people who can potentially chew and swallow but are unable to feed themselves.
2. Continue to reassess patients who are malnourished or at risk for malnutrition.
3. Monitor for refeeding syndrome.
C. Institution will
1. Ensure that all health care professionals who are directly involved in patient care should receive education and training on the importance of providing adequate nutrition.
D. QA/QI
1. Establish QA/QI measures surrounding nutritional management in aging patients.
E. Educational
1. Provided education and training includes
a. Nutritional needs and indications for nutrition support
b. Options for nutrition support (oral, enteral, and parenteral)
c. Ethical and legal concepts
d. Potential risks and benefits
e. When and where to seek expert advice
2. Patient and/or caregiver education includes how to maintain or improve nutritional status as well as how to administer, when appropriate, oral liquid supplements, enteral tube feeding, or parenteral nutrition.
VII. FOLLOW-UP MONITORING
A. Monitor for gradual increase in weight over time.
1. Weigh patient weekly to monitor trends in weight.
2. Daily weights are useful for monitoring fluid status.
B. Monitor and assess for refeeding syndrome (Skipper, 2012).
1. Carefully monitor and assess patients the first week of aggressive nutritional repletion.
2. Assess and correct the following electrolyte abnormalities: hypophosphatemia, hypokalemia, hypomagnesemia, hyperglycemia, and hypoglycemia.
3. Assess fluid status with daily weights and strict intake and output.
4. Assess for congestive heart failure in patients with respiratory or cardiac difficulties.
5. Ensure caloric goals will be reached slowly, over more than 3 to 4 days to avoid refeeding syndrome when repletion of nutritional status is warranted.
6. Be aware that refeeding syndrome is not only exclusive to patients started on aggressive artificial nutrition, but may also be found in older adults with chronic comorbid medical conditions and poor nutrient intake started with aggressive nutritional repletion via oral intake.
VIII: RELEVANT GUIDELINES
A. Preoperative nutrition assessment
1. ACS NSQIP®/AGS (2012)
B. Preoperative fasting
1. ASA (1999)
2. Lambert and Carey (2015)
C. Nutrition interventions
1. Bauer et al. (2013)
2. Sobotka et al. (2009)
3. Ukleja et al. (2010)
4. Volkert et al. (2006)
ABBREVIATIONS
ACS | American College of Surgeons |
ADL | Activities of daily living |
AGS | American Geriatrics Society |
ASA | American Society of Anesthesiologists |
BMI | Body mass index |
IADL | Instrumental activities of daily living |
MNA | Mini-Nutritional Assessment |
NPO | Nothing by mouth |
NSQIP | National Surgical Quality Improvement Program |
QA/QI | Quality assurance/quality improvement |
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