malnutrition: where are we headed? symposium... · marasmus 3 5% over one mo., 7.5 over three mo.,...
TRANSCRIPT
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Malnutrition:
Where are we headed?
Kris M. Mogensen, MS, RD-AP, LDN, CNSC
Team Leader Dietitian
Brigham and Women’s Hospital
Instructor
Boston University College of Health and Rehabilitation Sciences:
Sargent College
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Disclosures
• I have no disclosures related to this
topic
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• It helps to look back before we look
forward, so:
– Review prior malnutrition efforts
– What’s happening with Academy-
ASPEN characteristics
– Where are we headed?
Objectives
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Kickin’ it Old School
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JAMA 1936
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Nutrition Today
1974
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JPEN
1977 – Issue 1!!
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SGA!
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“Old” Evaluation Parameters
• % IBW
• % UBW
• Presence of fat/muscle wasting
• Presence of edema
• Adequacy of intake
• Circulating proteins
• Anergy
• Other direct anthropometric measurements
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Old Malnutrition Diagnoses
• Kwashiorkor
• Marasmus
• Mild, moderate, severe protein-calorie
malnutrition
• Protein-calorie malnutrition, NOS
Old Malnutrition Diagnoses
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Blast from the Past!
From ~ 1992!
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# of
Criteria Wt loss IBW wasting
Inadequate
energy intake Albumin*
Severe PCM 3 > 15% in 6
mo. < 70% yes yes < 2.1
Moderate
PCM 2
10%-15%, in
6 mo. 70%-84% no no < 2.7
Mild PCM 2 5%-9% in 6
mo. 85%-94% no no < 3.4
Marasmus 3
5% over one
mo., 7.5
over three
mo., 10%
over six mo.
<94% yes yes WNL or slightly
decreased
Unspecified
PCM
A patient at nutritional risk who may have a single nutrient deficiency,
multiple micronutrient deficiencies, overt fat/muscle wasting without
supporting weight history to fit into another category, prolonged
hypocaloric intake and high metabolic demand, etc.
BWH Old Criteria
*RDs trained not to use if inflammation or other confounder present
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Malnutrition Outcomes:
Old Characteristics
CCM 2015
CCM 2015
JPEN epub 2016; print Feb 2017
JPEN epub 2016
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Moving into modern times…
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Etiology-Based Malnutrition Diagnoses
From: White JV et al. Consensus statement: Academy of Nutrition and Dietetics and American
Society for Parenteral and Enteral Nutrition: Characteristics recommended for the identification
and documentation of adult malnutrition (undernutrition). JPEN 2012
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2012 Malnutrition Clinical
Characteristics Parameters
• Insufficient energy intake
• Weight loss
• Loss of muscle mass
• Loss of subcutaneous fat
• Localized or generalized fluid
accumulation that may sometimes mask
weight loss
• Diminished functional status as measured
by hand grip strength From: White JV et al. Consensus statement: Academy of Nutrition and Dietetics and American Society for Parenteral and
Enteral Nutrition: Characteristics recommended for the identification and documentation of adult malnutrition
(undernutrition). JPEN 2012
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Evaluation of Energy Intake
Kondrup K. Clin Nutr. 2001
Intake <75%
of needs, no
weight
maintenance
or gain
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Weight Loss Evaluation
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Physical Examination
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Hand Grip Strength
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Where are we headed?
First stop: Validation!
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Validation of the Academy/ASPEN Malnutrition Clinical
Characteristics. Hand RK et al. JAND 2016
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Current research with 2012 Adult
Malnutrition Clinical Characteristics
• Nicolo M et al. Feasibility of accessing data in hospitalized patients to
support diagnosis of malnutrition by the Academy- A.S.P.E.N.
malnutrition consensus recommended clinical characteristics. JPEN
2014;38:954-959
• Hand RK et al. Validation of the Academy/ASPEN Malnutrition Clinical
Characteristics. J Acad Nutr Diet. 2016
• Hiller LD et al. Difference in composite end point of readmission and
death between malnourished and nonmalnourished veterans assessed
using Academy of Nutrition and Dietetics/American Society for
Parenteral and Enteral Nutrition Clinical Characteristics. JPEN epub Sept
2016
• Mulasi U et al. Malnutrition identified by the Academy of Nutrition and
Dietetics and American Society for Parenteral and Enteral Nutrition
consensus criteria and other bedside tools is highly prevalent in a
sample of individuals undergoing treatment for head and neck cancer.
JPEN epub Oct 2016
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Feasibility of accessing data in hospitalized patients to
support diagnosis of malnutrition by the Academy-
A.S.P.E.N. malnutrition consensus recommended clinical
characteristics. Nicolo M et al. JPEN 2014
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Validation of the Academy/ASPEN
Malnutrition Clinical Characteristics. Hand RK et al. JAND 2016
Clinical Characteristic Evaluated?
Intake 96%
Wgt loss 92%
Muscle 98%
Fat 100%
Edema 98%
Hand grip 64%
28 patients enrolled in the study
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Validation of the Academy/ASPEN Malnutrition
Clinical Characteristics. Hand RK et al. JAND 2016
• Was there agreement between RDs?
– 24 of 28 had evaluation done by 2 RDs
• Context: agreed ~ 88% of the time
• Diagnosis: agreed for ~ 67% of pts
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Validation of the Academy/ASPEN
Malnutrition Clinical Characteristics. Hand RK et al. JAND 2016
• Full outcome data for 11 pts
– Malnourished pts had
• longer LOS
• higher charges
• more frequent ED visits
• More frequent readmissions
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Difference in composite end point of readmission and death between
malnourished and nonmalnourished veterans assessed using
Academy of Nutrition and Dietetics/American Society for Parenteral
and Enteral Nutrition Clinical Characteristics. Hiller LD et al. JPEN epub 2016
• Retrospective medical record review
• Used all characteristics except hand grip
strength
• Matched malnourished vs nonmalnourished:
202 in each group
• Composite end point: 30 day readmission
rate and 90 day mortality rate
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Difference in composite end point of readmission and death between
malnourished and nonmalnourished veterans assessed using
Academy of Nutrition and Dietetics/American Society for Parenteral
and Enteral Nutrition Clinical Characteristics. Hiller LD et al. JPEN epub 2016
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Difference in composite end point of readmission and death between
malnourished and nonmalnourished veterans assessed using
Academy of Nutrition and Dietetics/American Society for Parenteral
and Enteral Nutrition Clinical Characteristics. Hiller LD et al. JPEN epub 2016
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Comparisons to other
markers…
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Malnutrition Identified by the Academy of Nutrition and Dietetics and
American Society for Parenteral and Enteral Nutrition Consensus
Criteria and Other Bedside Tools is Highly Prevalent in a Sample of
Individuals Undergoing Treatment for Head and Neck Cancer. Mulasi U et al. JPEN epub 2016
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Malnutrition Identified by the Academy of Nutrition and Dietetics and
American Society for Parenteral and Enteral Nutrition Consensus
Criteria and Other Bedside Tools is Highly Prevalent in a Sample of
Individuals Undergoing Treatment for Head and Neck Cancer. Mulasi U et al. JPEN epub 2016
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Validation, refining the
characteristics, and
more…where do we go from
here?
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Functional Status and
Outcomes
CCM 2016
Surgery 2016
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Functional Status and
Outcomes • Formal PT assessment using the
Functional Independence Measure
– Independent, low, intermediate, high, and very
high risk
• High & very high risk
– Increased odds of 90-day post-discharge
mortality in ICU and trauma patients
– Higher prevalence of malnutrition in these
groups
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Crit Care
Med. 2016
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Functional Status and
Outcomes
• Can we collaborate with other
colleagues evaluating patients? – Could the PT scoring system be part of our
malnutrition characteristics in adults?
– Are our OT colleagues measuring hand grip
strength?
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Measures of Muscle Mass
• What are the roles of
– BIA
– CT
– Ultrasound
• Will these move into prime time?
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Role of Metabolomics?
Mogensen et al. JPEN
2017
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Coding and Data Collection
• We need to continue to work on
getting malnutrition coded
appropriately
• Not just a $$$ issue, but allows for
ongoing research for prevalence and
outcomes
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Data Collection and Storage
• If you are still in your building phase
of your EHR or you actually have
programmers who want to work with
you…
– Document data in a structured format
– Limit free text for data
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Treatment of Malnourished
Patients
• Is there a difference in clinical
response in malnourished vs. well
nourished patients?
• How do we study this?
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Conclusions
• Validation studies of current malnutrition
characteristics are in progress
• Will there be refinement of these characteristics
in the future?
• Keep collecting data and outcomes! Push for
appropriate coding!
• I hope that future research includes other
evaluation tools to expand the characteristics
• Finally, my hope is that future research evaluates
impact of nutrition interventions for malnourished
patients
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Thank you!