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Recognizing Malnutrition in Older Patients

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By Debra Wood, RN, contributor

August 27, 2014 - Would you know if your older patient was suffering from malnutrition?

More than half of older adults treated in a North Carolina emergency department were malnourished or at risk of malnutrition, yet nurses rarely picked up on the problem, according to a study from the University of North Carolina at Chapel Hill.

“Malnourishment is an up and coming discussion in geriatrics,” said lead author Greg F. Pereira, BSPH. “We were quite surprised [at the results].”

Pereira and colleagues conducted a cross-sectional study of 138 cognitively intact patients age 65 years and older seen in the emergency department, which treats a representative sample of patients who may not have other opportunities to access health care. They found and reported in the journal Annals of Emergency Medicine that 16 percent were malnourished. An additional 44 percent of older adults met the criteria for being at risk for malnutrition, according to a validated tool.

Those results were consistent with prior research.

Sabrina Pickens: Aging contributes to malnutrition.
Sabrina L Pickens, PhD, MSN, GNP-BC, ANP-BC, explained the normal aging process contributes to malnutrition.

Sabrina L Pickens, PhD, MSN, GNP-BC, ANP-BC, an instructor at the University of Texas Health Science Center at Houston (UTHealth) School of Nursing, reported that prior studies had found 15 percent to 50 percent of older adults are malnourished, and in the hospital setting, the rate increases to 20 percent to 60 percent.

“It is a common problem,” Pickens said. “Malnutrition is associated with increased mortality.”

It also contributes to reduced weight and muscle mass, which can affect functional status, said Nancy Copperman, MS, RD, CDN, corporate director of public health initiatives at North Shore LIJ Health System in Great Neck, N.Y.

Malnutrition and patient health 

“Malnutrition is associated with a lot of chronic conditions, and functional and cognitive declines,” Pereira said. “Malnutrition is multifactorial.”

Pickens explained the normal aging process contributes to malnutrition, as people experience a decrease in taste and olfactory senses. Older adults tend to get full faster and have less of an appetite. They also might lack the financial resources to purchase healthy foods or be unable to get to the store. Elderly patients may be at risk for neglect.

Vaunette P. Fay, PhD, RNC, FNP, GNP, a professor of nursing at UTHealth School of Nursing, added that medications often bring on anorexia, dentition may be poor or difficulty swallowing may pose problems.

Social isolation and functional limitations may play a big role in malnutrition, Copperman said.

Vaunette Fay: Malnutrition in older adults is often missed.
Vaunette P. Fay, PhD, RNC, FNP, GNP, said malnutrition in the elderly is under-recognized.

“Eating is a very social thing, and if you don’t have anyone to eat with, you may stop,” Fay added.

Peneira said he had expected with the federal Supplemental Nutrition Assistance Programs (SNAP), congregate meals served in community settings and Meals on Wheels, older adults had access to food. But those programs often are underutilized.

Patients with dementia may forget to eat or how to feed themselves, Pickens added. Depressed patients may lack appetite or will not want to eat or drive to the store to purchase food.

The UNC study found an association between malnutrition and depression. Peneira suggested screening for both depression and malnutrition in older adults. But that doesn’t always happen.

Malnutrition and nursing care 

Nurses and physicians caring for the malnourished patients in the UNC study made no indication of it in their notes. In 16 of the 22 patients found to be malnourished, the triage nurse reported no problem with malnutrition. In the other six cases, the nurse had not completed the single-item assessment. Nurses missed all cases of malnutrition.

Nurses tend to be looking at more acute issues in the emergency department, not long-term problems such as nutrition, said Copperman, who was not surprised the nurses missed that. She indicated nurses in home care and other settings have more time to focus on nutrition, but all nurses could adopt a “nutritional lens” and focus on the changes that occur over time.

“Nurses need an increased awareness,” Fay said. “Malnutrition is under-recognized.”

While signs of malnutrition such as dull and brittle hair may be present, Pickens said nurses cannot tell just by looking and should assess for malnutrition. Even people who are obese may be malnourished, based on albumin levels.

Older adults may eat baked goods or chews high in fat, because they are easy to consume. But these foods lack proteins and other nutrients the body needs.

Fay encouraged nurses to resume foods as soon as possible after a test or surgery, and to assess if the patient needs help ordering food or with setting up the meal tray or whether getting the patient up to a chair might help with appetite.

The paper suggests sip feeds, with oral supplements, such as Ensure or Boost, can assist older adults with weight gain and decrease the rate of malnutrition. Fay explained, however, that some people do not like the taste, and such snacks may ruin the person’s appetite for meals.

Perhaps a less restrictive diet would help boost a patient’s appetite. Fay suggested instructing older, malnourished diabetic patients to avoid concentrated sweets, or for sodium restriction patients, to reduce consumption of processed foods or not add salt at the table.

“Putting them on a real strict diet may be counterproductive,” Fay said. “Because then they are not going to eat, and you have all of the problems malnutrition brings.”

Clinicians must determine the cause for the malnutrition. Pickens suggested involving the interdisciplinary team and obtaining a referral for a dietician consult or a social work consult to deal with transportation or other issues.

“Malnutrition is a common condition that is easy to treat, and referral systems are in place,” Pereira said. “Screening and a simple referral have the potential to improve [patients’] long-term outlook.”

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