nutritional supports for improved health outcomes...
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Nutritional supports for improved health outcomes in older adults
Kathryn Star, PhD, RD
Objectives
• Understand the impact of malnutrition on the older patient
• Recognize factors in older adults that contribute to nutritional risk
• Identify nutritional risk and malnutrition in older patients
• Describe nutrition optimization and its associated benefits
Malnutrition is a Critical Issue
van Stijn M, et al., JPEN, 2013; White JV, et al., J Acad Nutr Diet, 2012
Consequences of Undernutrition
• Precedes disease and hospitalization• Loss of lean mass and bone• Slow wound healing• Longer hospitalization stays• Higher readmission rates• Increased mortality
NUTRITIONAL RISK
UNDER‐NOURISHEDUNDER‐WEIGHT
UNDER‐ NOURISHEDOBESE
NUTRITIONALLY VULNERABLE
Physiological/Biomedical
Psycho/Social
Economical
Psycho/Social EnvironmentalEconomical
Aging
Aging Related Protein Intake Shortfalls
Bauer J, et al. J Am Med Dir Assoc. 2013;14:542‐549
Prevalence of Malnutrition Across the Continuum of Care
Community-dwelling Older Adults
• Psycho/ Social– Mental health– Cognition– Loneliness– Social Isolation– Lack of social support– Alcoholism– Bereavement– Eating alone
• Environmental/Economic– Financial constraints – Access to food– Food preparation– Living alone– Transportation– Neighborhood walkability– Safety
Porter Starr KN, McDonald SR, Bales CW. Current Nutrition Reports. 2015:1‐9.
Hospitalized Older Adults
• Comorbidity• Admitting illness/ surgery• Medications• Restrictive diets• NPO orders• Meal interruptions• Food preference• Psycho/ Social
Porter Starr KN, McDonald SR, Bales CW. Current Nutrition Reports. 2015:1‐9.
Older Adults in Post-acute Care/ LTC
• Communication during any transition– Medications– Dietary preferences/ needs
• Depression• Swallowing issues• Eating/ chewing difficulties• Immobility/ functional deficits• Insufficient staffing
Porter Starr KN, McDonald SR, Bales CW. Current Nutrition Reports. 2015:1‐9.
Challenges of Identifying Malnutrition
• American College of Surgeons – Routine nutritional status screen– Preoperative nutrition intervention
• American Medical Association– “comprehensive nutritional screening,
assessment and management”• No universal, validated screening tool• Occurs day of hospital admission
– What about those not admitted to hospital
How would you know if someone was at nutritional risk or
malnourished?
BMIWeight
Status
Below 18.5 Underweight
18.5 – 24.9 Normal
25.0 – 29.9 Overweight
30.0 and Above Obese
23.0
23.0
Identifying Malnutrition
• Albumin and pre-albumin are markers of inflammation NOT NUTRITIONAL STATUS
• AND/ASPEN Nutritional Focused Physical Exam – Gold-standard
• Validated Nutrition Screening– Nutritional Risk Screener-2002
• Validated Nutrition Assessment– Patient Generated- Subjective Global Assessment
ASPEN criteria (2 of the following)
• Weight loss – occurs at any BMI• Insufficient energy intake – <50-75% of
estimated needs • Loss of muscle mass – physical exam• Loss of subcutaneous fat – physical exam• Fluid accumulation – localized or generalized• Diminished function – Hand grip strength
Tappenden KA, et al. J Acad Nutr Diet. 2013;113(9):1219‐1237
Mild to Moderate MalnutritionAcute Illness/Injury Chronic Illness
Weight Loss1‐2%/1 week5%/1 month
7.5%/3 months
5%/1 month7.5%/3 months10%/6 months20%/1 year
Energy Intake <75% for >7 days <75% for ≥1 month
Body Fat Mild Depletion Mild Depletion
Muscle Mass Mild Depletion Mild Depletion
Fluid Accumulation Mild Mild
Hand Grip Strength N/A N/A
Severe Malnutrition in AdultsAcute Illness/Injury Chronic Illness
Weight Loss>2%/1 week>5%/1 month
>7.5%/3 months
>5%/1 month>7.5%/3 months>10%/6 months>20%/1 year
Energy Intake ≤50% for ≥5 days ≤75% for ≥1 month
Body Fat Moderate Depletion Severe Depletion
Muscle Mass Moderate Depletion Severe Depletion
Fluid Accumulation Moderate/Severe Severe
Hand Grip Strength Not Recommended in ICU
Reduced for Age/Gender
NUTRITION INTERVENTION
What do we do about it?
• Refer to a Registered Dietitian Nutritionist• Always assess using standard tools and
act upon the findings• Avoid therapeutic diets• Improve the social aspects of eating• Dental care• Physical activity
Community• Supplemental Nutrition Assistance Program
(SNAP)• Geriatrics Workforce Enhancement Program• USDA Senior Farmers’ Market Nutrition
Program• Older American’s Act Nutrition Program
– Home delivered meals– Congregate meal programs– Nutrition education
Hospital
• Smaller meals with snack in between• Animal protein• Energy dense foods (i.e. healthy fats)• Nourishing fluids (i.e. milkshakes, soups)• Avoid therapeutic diets• Minimize NPO status• Use enteral nutrition with high protein
Surgical Patient• Nutritional support should begin 7-10 days
prior to surgery with established malnutrition– Oral supplementation preferred
• Following surgery, enteral, or parenteral nutrition should begin if eating has not begun by day 5
• Elective surgery should be delayed if patient is severely malnourished and nutrition intervention should be implemented immediately
Hospital: Oral Nutrition Supplements
• Use with a comprehensive treatment plan• Modest consistent weight gain• Consistency in intake across care settings • Provide a cup and/ or ice • Does not reduce meal intake/ total energy
intake when given 30-60 min before meals• Mortality benefit in undernourished
McDonald, SR. Beverage Impacts on Health and Nutrition: Oral Nutritional Supplementation Using Beverages for Older Adults. Humana Press, 2016.
• Reducing Diet Restrictions– American Dietetic Association Position Paper
supports removing restrictions as a way of enhancing food intake
– Emphasizes “person-centered” and “resident-centered” care
Niedert, K.C. J Am Diet Assoc. 2005;105:1955.
Post-acute care/ LTC
Nutrition Has To Be A Priority
• All providers must be empowered to influence nutrition decisions
• Recognize and diagnose all patients at risk• Intervention needs to be comprehensive and
promptly implemented before and after surgery.
• Nutrition care plan need to be documented and shared across care settings
• Refer to a Registered Dietitian Nutritionist
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