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Y2 - BRS - GI > Malnutrition and Nutritional Assessment > Flashcards

Malnutrition and Nutritional Assessment Flashcards

1
Q

Why may malnutrition occur?

A

Starvation
Disease
Ageing

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2
Q

What is malnutrition?

A

A state resulting from lack of uptake or intake of nutrition

Leading to altered body composition and body cell mass

Leading to diminished physical and mental function and impaired clinical outcome from disease

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3
Q

In who is malnutrition most prevalent in?

A

Youngest and oldest adult age groups (over 65) - curvilinear (‘U’ shape) relationship as age increased

More common in women than men

Oncology and care of the elderly walls

Those with Gastrointestinal disease / dysfunction

Long term condtions e.g. diabetes

Chronic progressive conditions e.g. cancer or dementia

Those who abuse drugs or alcohol

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4
Q

What percentage of people admitted to hospital are malnourished at point of admission according to BAPEN?

A

1 in 3

33%

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5
Q

What percentage of people lose weight after discharge?

A

70%
Mainly fat-free (muscle) mass

Greatest weightloss seen in those undernourished upon admission

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6
Q

What factors exacerbate malnutrition (and consequently weight loss) during their stay at hospital?

A

Multi-factorial issue:
Disease related anorexia
Stress - increased demand of energy, proteins and micronutrients

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7
Q

What is disease related anorexia?

A

Loss of appetite as a result of pathophysiological mechanisms and modification of central regulation of feeding behaviour, which is observed in the presence of disease

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8
Q

Why is muscle broken down as a part of the weight loss from malnutrition in hospitals?

A

Metabolic response to stress = muscle breakdown to amino acids for gluconeogenesis and protein synthesis for the immune response and tissue repair

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9
Q

Why are patients with prior malnutrition more likely to experience significantly weight loss than others?

A

Patients with prior malnutrition who then develop acute illness have less reserve by which to face that illness

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10
Q

Why do people lose weight in hospital?

A

40% of food left on plate - less than 80% of the recommended protein and calorie intake by patients capable of eating
GI symptoms
Depression/Low mood
Quality of food
Lack of motivation
Food of secondary importance
Expectation / belief by patients of poor appetite during hospital stay, and appetite will return after discharge

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11
Q

What was the impact of malnutrition on recovery from surgery for duodenal cancer?

A

Post-op mortality 10x greater in those who had lost more than 20% of their body mass prior to surgery, than those who had lost less

Patients that are unable to mobilise adequate amounts of endogenous nitrogen in response to stress experience greater morbidity and mortality than those that are able to generate a catabolic response from adequate stores of muscle tissue

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12
Q

What did the ONS reveal about hospital deaths and malnutrition in 2016?

A

Direct cause 66 hospital deaths

Contributory factor 285 hospital deaths

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13
Q

How does malnutrition impact clinical outcomes?

A

Physical and function decline
Poorer clinical outcomes

Increased:
Mortality
Septic and post surgical complications
Length of hospital-stay
Pressure sores
Re-admissions
Dependency 
Decreased:
Wound healing
Response to treatment
Rehabilitation potential
Quality of life
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14
Q

What is the cost of malnutrition in England per year?

A

£ 19.6 billion = 15% of total expenditure on health and social care

Mostly in secondary health care

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15
Q

How much more costly is it to treat a malnourished patient VS a well-nourished patient?

A

Health and social costs = 3x more in malnourished than well-nourished patients

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16
Q

What will happen to the costs of malnourishment in the future?

A

Rise - due to ageing population

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17
Q

How much can the NHS save yearly by identifying and treating malnutrition?

A

Up to 65 million

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18
Q

How is malnutrition diagnosed in acute settings?

A

Malnutrition universal screening tool (MUST) - most commonly used in the UK to screen for adult’s malnutrition

A simple tool to identify risk - based on BMI, unplanned weight loss and presence of acute disease

Carried out by any HCP

This is not assessment or diagnosis

Categorises individuals as low, medium and high risk of malnutrition

Provides immediate guidelines based on category

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19
Q

When is MUST used?

A

Malnutrition screening required within 6hrs of hospital admission and weekly thereafter

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20
Q

What are the limitations of MUST?

A

Can miss malnourished in clinical populations e,g. overhydration (ascites, oedema)

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21
Q

What happens when a patient triggers as a result of the MUST screening process?

A

Referred to dietitian for assessment of nutritional and functional status

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22
Q

What is nutrition assessment?

A

A comprehensive evaluation carried out by a registered dietitian for defining nutrition status

Uses anthropometric measurements, biochemical data, medical, social and nutritional histories, and physical examination

A systematic process of collecting & interpreting information to determine the nature and cause of the nutrient imbalance

Need to gather adequate info to make nutritional judgement

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23
Q

What is anthropometry?

A

Measurement of body

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24
Q

What is conducted in a anthropometry assessment?

A

Scale for weight - recent unplanned changes in weight reflect acute changes in protein energy status = associated with increased length of stay, morbidity and mortality

BMI is insignificant - due to influence of gender, ethnicity and age being ignored

Midarm muscle circumference - assessment of lean body mass = reduced length of hospital stay and improved functional ability

Multifrequency bioelectrical impedance analysis - renal and haematology patients

CT for muscle content and fat and their distribution - expensive and radiation

Hand grip strength - reflects upper extremity muscle strength, which responds earlier to malnutrition - muscle strength independent of muscle mass can predict morbidity and mortality
(reduction in mortality risk per 1kg increase in handgrip strength)

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25
Q

What biochemistry is used?

A

Forms part of nutritional assessment

Tests used to estimate nutrient availability in fluid and tissues = critical to assess clinical nutrient deficiencies

Measurements of micronutrients - expensive, therefore must have justified reason to request this

26
Q

What can skew the results of the biochemistry tests used to determine micronutrient measurements?

A

Acute inflammatory response skews response

Therefore, not measured until CRP =< 10 micrograms /L

27
Q

What is relevant from a medical history?

What is included in a nutritional / dietary history?

A 
Alcohol and drug use
Increased metabolic needs
Increased nutritional losses
Chronic disease
Recent major surgery or illness
Surgery of GI tract esp. 
Anorexia
Loss of sense of taste / smell
Excessive alcohol intake
Poor fitting dentures
Allergies
Fad dieting
Usual patterns of food intake
Chewing or swallowing problems 
Aversions
Cultural, religious, ethical Dietary restrictions
28
Q

Why might the social history of a patient also be relevant for a dietitian?

A

Socioeconomic status = ability to purchase food independently

Physical or mental disabilities

Eating alone

29
Q

What is indirect calorimetry?

How is it carried out / measured?

A

Most reliable method to measure energy expenditure and guide energy prescription

Measurement of resting metabolic rate using a respirator gas exchange canopy

30
Q

What are the limitations of indirect calorimetry?

What is used instead?

A

Restricting in clinical practice

Predictive equations estimating metabolic rate are used in clinical practice instead, to determine estimated energy requirement

31
Q

What is the use of predictive equations clinically?

A

Predict (estimate) resting metabolic rate = used to calculate nutritional requirement based on patient’s gender, weight, height, and level of physical activity

32
Q

What are limitations of the predictive equations?

So what are they used for actually in clinic?

A

Low to moderate performance = best reaching accuracy of 70%

Used as a baseline to determine first set of nutrition requirements - assessment of status determined nutritional diagnosis, outcomes, and intermediate goals

33
Q

What is nutritional requirement?

A

Average dietary intake that is predicted to maintain energy balance in an adult of a defined age, gender, weight, height and physical activity

34
Q

What is done once malnutrition has been diagnosed?

A

Plan
Implement
Monitor
Evaluate

35
Q

When should nutrition support be considered according to NICE guidelines?

A
  1. Patients who are malnourished =
  • A BMI of < 18.5 kg/m2 or
  • Unintentional weight loss >10 % past 3 - 6 / 12 or
  • BMI < 20 kg/m2 + unintentional weight loss > 5 % past 3 – 6 / 12.
  1. At risk of malnourishment =
    - 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.
36
Q

What is artificial nutrition support?

A

The provision of enteral or parenteral nutrients to treat or prevent malnutrition

37
Q

What is used to decide how malnutrition is treated?

What is the first line of delivery of treatment?

A

Stratton and Elia flowchart is used

If oral route is safe and possible - always first and preferred approach

Cases where oral route is not possible - is GI tract function and accessible? If so, enteral (tube to gut) feeding needs to be considered. If GI tract = non functional or accessible, parenteral (drip into blood)nutrition is then considered

38
Q

What implications does enteral nutrition have?

A

Ethical and Legal

ESBEN have guidelines on the ethical aspects of artificial nutrition and hydration

39
Q

Why is enteral support superior to parental?

A

Enteral = uses the gut

Where parental nutrition is used, aim to return to enteral (oral feeding) as soon as clinically possible

40
Q

How is access decided for enteral feeding?

A

Is gastric feeding possible?

Yes = Naso-gastric tube (NGT)
No = Naso-duodenal (NDT) / naso-jejunal tube (NJT)

Long term (> 3 months) = Gastrostomy / jejunstomy tube can be inserted

41
Q

Who determines the type of nutritional feed to put down the feeding tube?

A

Dietitian

Nutritional feed dependent on multiple factors –> renal, low sodium, respiratory, immune, elemental, peptide

42
Q

What are the complications associated with enteral feeding?

A

Misplaced NGTs (21 deaths and 79 cases of harm between 2005-2011)

Mechanical - misplacement, bloackage, buried bumper

Metabolic - hyperglycaemia, deranged electrolytes

GI -aspiration, nasopharyngeal pain, laryngeal ulceration, vomiting, diarrhoea

43
Q

What is done clinically when an NGT is placed?

A

When an NGT is placed, an aspirate needs to be obtained from the tube indicating a pH of 5.5 or less = reflects gastric contents (acidity) in the stomach

If pH >5.5, a chest x-ray is indicated

44
Q

What is parenteral nutrition?

A

Parenteral nutrition (PN): The delivery of nutrients, electrolytes and fluid directly into venous blood

45
Q

When is this used?

A

An inadequate or unsafe oral and/or enteral nutritional intake

OR

A non-functioning, inaccessible or perforated gastrointestinal tract

46
Q

How is access for parenteral nutrition gained?

.

A

Central venous catheter (CVC): inserted into the subclavian, jugular or femoral veins, with tip at superior vena cava and right atrium

Or peripherally inserted CVCs at the antecubital dossea, with tip still at the superior vena cava

Different CVCs for short / long term use

47
Q

Where can CVCs be inserted?

A

Subclavian
Jugular
Femoral
Antecubital fossa

48
Q

What is the parenteral nutrition bag composed of?

A

Composed by dietitian

Ready made or prescribe a “scratch” bag

MDT and dietitian decide on fluid and electrolyte targets for that day

49
Q

What are the complications associated with parenteral nutrition?

A 
Mechanical = begins during insertion
Pneumothorax
Haemothorax
Thrombosis
Cardia arrhythmias
Thrombus
Catheter occlusion
Thermophlebitis
Extravasion
Metabolic = begins once starting the feed
Deranged electrolytes
Hyperglycaemia
Abnormal liver enzymes
Oedema
Hypertriglycerideamia

Catheter-related =
Infections / septicemia

50
Q

How does nutrition support benefit the malnourished patient?

A

Lowers mortality
Reduction in readmission
Weight increase
Significantly better outcomes - including all-cause mortality, intensive care unit admission, non-elective hospital readmissions, major complications, and functional status at day 30

51
Q

What is albumin?

A

Most abundant circulating protein in the plasma of healthy individuals

Albumin synthesised in the liver - 10-15g produced daily

Low plasma albumin = poor prognosis

A negative acute phase protein = decreased plasma albumin when increased inflammation

52
Q

What is albumin synthesis stimulated by?

A

Albumin synthesis is stimulated by hormones e.g. insulin, cortisol and GH (growth hormone)

53
Q

What is albumin synthesis inhibited by?

A

Pro-inflammatory substances eg. IL-6, tumour necrosis factor (TNF)

54
Q

What happens in acute inflammatory phase?

A

Inflammatory stimulus = activation of monocytes & macrophages = release cytokines

Cytokines act on liver to stimulate production of some proteins whilst downregulating production of others e.g. albumin

Albumin levels decrease - additionally from degradation and transcapillary loss

55
Q

Is albumin a valid marker of malnutrition in the acute hospital setting?

A

No

Albumin synthesis reduces in response to inflammation - therefore not a valid marker of nutritional statur nor an indicator for nutritional intervention in the acute setting

Best evidence = hypoalbuminaemia in obese trauma patients

Dietitian focused on the aetiology / impact of the inflammatory state on nutritional status rather than albumin levels

56
Q

What is refeeding syndrome?

A

A group of biochemical shifts & clinical symptoms that can occur in the malnourished or starved individual on the reintroduction of oral, enteral or parenteral nutrition

57
Q

What happens in the body during starvation?

A

During starvation, body aims to utilise energy stores:

  • Reduction in insulin secretion
  • Increase in glucagon secretion to produce glucose
  • Glycogen stores in the liver, amino acids in the skeletal muscle = metabolised into glucose
  • There deplete within 24-72hrs, metabolism shifts to derive energy from ketone production due to free fatty acids being released from fat stores

Decrease in basal metabolic rate - brain adapts to using ketone bodies instead of glucose - results in loss of fat mass

Reduce energy expenditure by reducing action on cellular pumps - electrolytes are then able to leak across cell membrane = increase in extracellular water, total body water and Na+; but depletion in K+, Mg2+, and phosphate

Serum concentrations are maintained, but intracellular stores are depleted

Sodium and fluid leak into cells = leads to sodium and fluid intolerance

Micronutrient stores = depleted

Thiamine deficiency likely as it is water soluble and the body has limited stores

58
Q

Why is the shift to using free fatty acids so important?

A

Shift spares skeletal muscle breakdown and fat free mass is preserved to an extent

59
Q

What happens when carbohydrate is reintroduced after starvation?

A

Secretion of insulin - stimulates Na+/K+ ATPase pump activation - required Mg2+ as a co-factor

This drives potassium and phosphate into cells, and sodium and fluid out of cells into the ECF

Phosphate driven into cells = energy storage as ATP

ATP =
increased cellular uptake of glucose, magnesium, potassium and phosphate and subsequent reduction in extracellular concentrations

Thiamine = coenzyme in carbohydrate metabolism and deficiency can occur on refeeding in a vitamin B depleted patient

Increased uptake of solutes

Lower electrolytes in plasma - clinical manifestations

Carbohydrates = reduce sodium and fluid excretion = expansion of ECF resulting in refeeding oedema and fluid overload

60
Q

What are the consequences of Refeeding syndrome?

A

Arrhythmia, tachycardia,

Congestive heart failure - lead to cardiac arrest, sudden death

Respiratory depression

Encephalopathy, coma, seizures, rhabdomyolysis

Wernicke’s encephalopy

61
Q

According to NICE what are the criteria for defining the risk for refeeding syndrome (RFS)?

A

At risk: very little or no food intake for > 5 days

High risk: one or more of
- BMI less than 16 kg/m”2

  • Unintentional weight loss greater than 15% within the last 3–6 months
  • Very little or no nutritional intake for more than 10 days
  • Low levels of potassium, phosphate or magnesium prior to feeding

OR high risk: two or more of

  • BMI less than 18.5 kg/m”2
  • Unintentional weight loss greater than 10% within the last 3–6 months
  • Little or no nutritional intake for more than 5 days
  • A (PMH) history of alcohol abuse or drugs including insulin, chemotherapy, antacids or diuretics

Extremely high risk:
- BMI less than 14 kg/m^2

  • Negligible intake for more than 15 days
62
Q

What is the management for RFS?

A

Start with 10-20 kcal/kg
Of that, 40-50% of the energy will be carbohydrates
Micronutrients given from onset of feeding

Monitor and replace electrolytes daily following Trust policy

Administer thiamine from the onset of feeding following Trust policy - first dose fiven 30 mins before onset of initial feeding

Monitor fluid shifts and minimise risk of fluid and Na+ overload

Y2 - BRS - GI (14 decks)

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