Nutrition in elderly Flashcards
Malnutrition
Malnutrition is a state in which a deficiency of nutrients such as energy, protein, vitamins and minerals causes measurable adverse effects on body composition, function or clinical outcome. (NICE,2006)
Many potential causes of Malnutrition:
Health - Dementia, Acute or Chronic illness, taste change( can be due to medication), depression, nausea, vomiting, diarrhoea, constipation.
Physical - limited mobility, chewing or swallowing difficulty, dental issues.
Social - social isolation, poverty, drug or alcohol dependency.
Cycle of Malnutrition
Nutritional intake no longer meets nutritional requirements due to:
Reduced dietary intake which leads to
Poor nutritional status
Increased risk of malnutrition
Increases risk of infection and illness
Further adds to loss of appetite
Consequences of Malnutrition
Malnutrition is both a cause and a consequence of ill health.
It is common and increases a patient’s vulnerability to disease.
Physiological
Loss of body weight and muscle mass
Delayed wound healing
Reduced immunity
Increased frailty ( Low body weight and unplanned weight loss is NOT a normal part of ageing)
Higher mortality rate
Psychological
Depression / anxiety
Screening for Malnutrition
NICE guidance states that:
All hospital inpatients on admission and all outpatients at their first clinic appointment should be screened.
Screening should be repeated weekly for inpatients and when there is clinical concern for outpatients.
People in care homes should be screened on admission and when there is clinical concern.
Screening should assess BMI, percentage unintentional weight loss and should consider the time over which nutrient intake has been reduced.
The Malnutrition Universal Screening Tool (MUST) may be used to do this.
Treatment of Malnutrition
Methods to improve or maintain nutritional intake are known as nutrition support.
Options include:
Nutritional support via the enteral route:
ONS - Oral nutritional support - Fortified food, additional snacks and / or sip feeds
Enteral tube feeding - the delivery of nutritionally complete feed directly to the gut via a tube
Parenteral nutrition - the delivery of nutrition intravenously
Step 1- Dietary modification
Least invasive method - can significantly increase energy intake.
Aim is to increase energy and protein intake
Can increase the frequency of food consumed
Include a milk based drink
Encourage the use of snacks
Avoid low fat foods ( Add grated cheese, double cream or butter to dishes)
If poor dietary intake is due to mobility issues - support with feeding may be the only intervention that is required.
Ensure food is correct texture
Step 2 - Supplementary support
Supplementary support: These are specific dietary supplements for specific cases of malnutrition. Examples include: Maxijul super soluble, Pro-cal, Duocal super soluble.
Step 3 - Sip feeds
Sip feeds - should only be initiated when dietary modifications have not worked.
Should be used when nutritional intake cannot be met due to: Swallowing difficulties, sore mouth, loss of appetite, significant weight loss due to illness / treatment.
Should be used in addition to diet or as a meal replacement.
Usually drink based - listed in BNF. Many available depending on specific clinical requirements. (Ensure,Fortisip, Altraplen).
Step 4 - Enteral tube feeding
Enteral tube feeding - if oral intake is insufficient or unsafe.
NEED a functional GI tract
For example: Swallowing disorders post-stroke,Upper GI obstruction.
Can be given in separate doses (bolus) or continuously
Require more monitoring than steps 1-3.
Enteral tube feeding - types
Many types of feeding tubes, it is important to understand the differences
Gastric feeding - Into stomach
NG - Nasogastric tube - usually shorter term (less than 6 weeks)
PEG - Gastrostomy - Longer term support (more than 6 weeks)
Post-pyloric - Bypasses the stomach
NJ - Nasojejunal - Usually short term
Jejunostomy - longer term support
Types of enteral tube feed
Many types of feed depending on nutritional requirements and disease states:
High energy
Fibre rich
Low sodium
Feeds should NOT be diluted or additions made due to risk of bacterial contamination.
Various regimens available:
Bolus
Intermittent – cycle feeding over 16-20 hours
Continuous ( continuous or cycled regimens must be used in jejunal feeding as no stomach to act as reservoir)
Medication administration via feeding tubes
Feeding tubes can be used to administer medication via the GI tract if necessary.
This is a common query for pharmacists.
Most medications are not licenced for administration via feeding tubes and some medications are not suitable for administration via feeding tubes.
Risks of tube blockage which can be very problematic.
Consider the potential for interactions with medication and enteral feeds.
Ensure you know where to find this information and are able to explain to healthcare professions how medication should be administered via feeding tubes.
Medicines administration via feeding tubes
Medicines administered via an enteral feeding tube should be given separately from the feed. The tube should be flushed with water before and after each medicine and only after establishing compatibility with the feed.
Some drug-feed interactions :E.g. Phenytoin, tetracycline. ( What would you advise?)
Dispersible tablets or suspensions are preferable to syrups because of the effects of high osmolarity ( e.g Loperamide)
Tube blockage is common if adequate flushing is not performed after each administration of feed / medicine – some medicines are more likely to cause tube blockage.
Nutritional requirements
Dietitians will assess a patient’s nutritional status and history and recommend a regimen taking into account the recipient’s needs and preferences.
This will vary depending on previous intake / disease state etc.
NICE recommend:
25 to 35 kcal/kg/day total energy (including that derived from protein);
0.8 to 1.5 g protein (0.13 to 0.24 g nitrogen)/kg/day
30 to 35 ml fluid/kg (20-25ml/kg in frail) (with allowance for extra losses from drains and fistulae, for example, and extra input from other sources – for example, intravenous drugs)
adequate electrolytes, minerals, micronutrients (allowing for any pre-existing deficits, excessive losses or increased demands) and fibre if appropriate.
Re-feeding syndrome
Re-feeding syndrome can be defined as the potentially fatal shifts in fluids and electrolytes that may occur in malnourished patients on re-feeding following a period of starvation (NICE, 2006)
This is particularly common in patients receiving artificial refeeding, but is possible with oral re-feeding (particularly if oral nutritional supplements are prescribed).
What is re-feeding syndrome?
Re-introduction of nutrition after period of malnutriton/ starvation
Metabolic switch occurs from fat to carbohydrate metabolism.
This causes a surge in release of insulin
Resulting in uptake of glucose, phosphate, potassium and magnesium into the cells
This can lead to:
Low serum levels of the above electrolytes
Arrythmias
Heart failure
Can be fatal
How can we assess the risk of re-feeding?
People who meet the following criteria should be deemed at “high risk” of re-feeding.
Patient has 1 or more of the following:
* BMI less than 16 kg/m2
* unintentional weight loss greater than 15% within the last 3 to 6 months
* little or no nutritional intake for more than 10 days
* low levels of potassium, phosphate or magnesium before feeding.
Or
Patient has 2 or more of the following:
* BMI less than 18.5 kg/m2
*unintentional weight loss greater than 10% within the last 3 to 6 months
* little or no nutritional intake for more than 5 days
* a history of alcohol abuse or drugs including insulin, chemotherapy, antacids or diuretics
How can we treat / prevent re-feeding?
People at high risk of developing refeeding problems should be cared for by healthcare professionals who are appropriately skilled and trained and have expert knowledge of nutritional requirements and nutrition support.
Nutritional support should be introduced cautiously and monitored closely.
Immediately before and during the first 10 days of feeding:
Thiamine 200 to 300 mg daily,
Vitamin B co-strong 1 tablet, 3 times a day (or full dose daily intravenous vitamin B preparation, if necessary)
Multivitamin or trace element supplement once daily
Providing oral, enteral or intravenous supplements of(unless pre-feeding plasma levels are high):
potassium (likely requirement 2 to 4 mmol/kg/day)
phosphate (likely requirement 0.3 to 0.6 mmol/kg/day)
magnesium (likely requirement 0.2 mmol/kg/day intravenous, 0.4 mmol/kg/day oral)
Dysphagia
Dysphagia isthe medical term for swallowing difficulties.
Some people with dysphagia have problems swallowing certain foods or liquids, while others can’t swallow at all.
Clinical signs of dysphagia include:
Coughing or choking when eating or drinking / vomiting
Describing the feeling that food is “getting stuck”
a gurgly, wet-sounding voice when eating or drinking
Can lead to weight loss due to inadequate nutritional intake. Increased risk of aspiration which can lead to pneumonia.
SALT - Speech and Language therapists assess this and provide advice on management.
Patients with dysphagia require close observation and extra support to ensure that oral intake is compliant with SALT recommendations to ensure safety.
IDDSI - International Dyshpagia Diet Standardisation initiative
This is a global framework which provides standardised terminology to describe food and drink textures.
SALT recommendations for swallowing use IDDSI level to ensure recommendations are clear, consistent and standardised.
Parenteral nutrition
Administration of nutrition via the IV route (can be via central or peripheral vein)
Parenteral nutrition should be considered in people who are malnourished and meet either of the following criteria:
Inadequate or unsafe oral and or enteral intake
A non-functional, inaccessible or perforated GI tract.
Parenteral nutrition requires
MDT input ( Consultant, Pharmacist, Dietitian, Nutrition Specialist Nurse)
Extensive monitoring
TPN bags are made in pharmacy aseptic unit to meet patients specific needs, some are pre-made.
Benefits of enteral feeding
Physiologically favourable as maintains gut function.
Less risk of complications ( Infection, air embolism, electrolyte disturbances)
Cheaper & easier to monitor - less staff intensive
