6.9 - Malnutrition and nutritional assessment Flashcards
Define malnutrition.
A state in which deficiency, excess or imbalance, of energy, protein or other nutrients, results in a measurable adverse effect on body composition, function and clinical outcome
How does prevalence of malnutrition change by age?
- curvilinear relationship where highest rates of malnutrition are in youngest and oldest age groups
- more common in women than men
How does prevalence of malnutrition differ in wards?
Oncology and care of elderly wards have highest rates
How many people on admission to hospital have malnutrition?
1 in 3 –> shows a lot of malnutrition occurs in community
What % of people have lost weight at discharge and what is the weight loss in?
- 70% have lost weight at discharge - mainly lost muscle mass
- most weight loss seen in those who were initially malnourished at admission
What does hospitalisation exacerbate in relation to malnutrition?
Hospitalisation exacerbates nutrition risk
Generally, which groups are affected by malnutrition? (5)
- older people over 65, particularly if admitted to hospital
- people with long term conditions like diabetes, kidney disease and chronic lung disease
- people with chronic progressive conditions like cancer, dementia
- those who abuse drugs or alcohol
- patients with GI dysfunction
What can the causes of malnutrition in hospital be divided into? (3)
- reduced intake
- maldigestion, malabsorption
- altered metabolism
What can cause reduced intake related malnutrition in hospital? (9)
- contraindicated
- disease-related anorexia (loss of appetite due to pathophysiology and modification of central regulation of feeding behaviour)
- taste changes
- nil by mouth
- food options
- depression
- inactivity
- oral health
- fatigue
What can cause maldigestion/malabsorption related malnutrition in hospital? (4)
- function
- length
- losses
- drug-nutrient interactions
What can cause altered metabolism related malnutrition in hospital?
- injury
- shock (1-2 days) - nutrition goal: survival, reduced % energy expenditure
- catabolism (2 days-weeks) - nutrition goal: cover metabolic needs, energy expenditure rises and falls
- anabolism (after weeks) - nutrition goal: muscle recovery, energy expenditure stable
What is the impact of malnutrition on postoperative mortality?
- 1936: post-op mortality was 10x greater in those who had lost >20% bodyweight preoperatively, compared to those who had lost less (perforated duodenal ulcer surgery)
- 2022 - malnutrition directly caused 77 hospital deaths, and contributory factor to 436 hospital deaths
What does malnutrition cause overall?
Physical and functional decline, and poorer clinical outcomes
What does malnutrition increase? (6)
- mortality
- septic and post-surgical complications
- length of hospital stay
- pressure sores
- readmissions
- dependency
What does malnutrition decrease? (4)
- wound healing
- response to treatment
- rehabilitation potential
- quality of life
How much does malnutrition cost England per year?
- £19.6 billion –> 15% of total expenditure on health and social care
- most of costs are in secondary healthcare
- health costs said to be 3x greater for malnourished than well nourished patients
What is the order for diagnosing malnutrition?
- screen - a simple tool to identify risk, not assessment or diagnosis
- assess (dietitian) - a systematic process of collecting and interpreting information to determine the nature and cause of the nutrient imbalance
- diagnose - nutrition diagnosis
How can we screen for malnutrition?
- MUST (Malnutrition Universal Screening Tool) - based on BMI, unplanned weight loss and presence of acute disease
- categorises patients as being low, medium or high risk and gives guidelines for treating each
- carried out by any HCP
What is a limitation for using MUST as a screening tool for malnutrition?
Can miss malnourished populations e.g. where overhydration is common like in ascites and oedema, or where specific screening for functional impairment is desired
What does a dietitian look at when assessing patients for malnutrition? (9)
- anthropometry
- body composition
- function
- biochemistry
- clinical
- dietary
- social history
- physical exam
- requirements
Which two groups of people should nutrition support be considered for?
- malnourished
- at risk of malnutrition
What are the requirements for being malnourished? (3)
- BMI <18.5 kg/m2 OR
- unintentional weight loss >10% past 3-6 months out of last 12 months OR
- BMI <20kg/m2 + unintentional weight loss >5% past 3-6 months out of last 12 months
What are the requirements to be at risk of malnutrition? (2)
- have eaten little or nothing for >5 days and/or are likely to eat little or nothing for the next 5 days or longer OR
- have a poor absorptive capacity, and/or have high nutrient losses and/or have increased nutritional needs from causes such as catabolism
What is the algorithm of treatment of malnutrition? (Look at image on slide)
- is oral nutrition possible & safe?
-
Y = oral nutrition support - counselling, supplements, texture modification, thickeners; consider need for modified diet according to clinical condition e.g. reduced Na+, MCT, peptides
- regularly monitor intake, if inadequate –> enteral tube feeding - short term (fine bore naso-enteral tube) or long term, regularly monitor adequacy
-
N = is GI tract functional & accessible?
- Y = enteral tube feeding
- N = parenteral nutrition (if limited tube feeding possible, enteral tube feeding)