Geriatric Nursing and Nutritional Issues

What are nutritional problems in old age their assessment nutritional planning and nursing interventions.

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).