Nutritional Risks and Determinants in Older Adults Flashcards
malnutrition in older adults
often due to undernutrition in older adults (energy and/or nutrients), and can include obesity
sarcopenia in older adults
age-related loss of muscle mass and strength
cachexia in older adults
disease-related loss of muscle mass and strength; in the presence of fat mass loss
* underlying disease is the driver
malnutrition in older adults across different settings
- most malnourished in rehabs and hospitals
- community dwellers are the least malnourished
What are comprehensive assessments of nutritional status in older adults?
Used to diagnose malnutrition/undernutrition and develop and implement a treatment plan
* anthropometric
* clinical
* biomechanical
* dietary intake
Anthropometric assessments
- body mass index (BMI) - not great though
- body composition (skin folds, BIA, DXA)
- circumference
- unintentional weight loss of more than 5% BW in 1 month, 7.5% BW in 3 months, 10% BW in 6 months
clinical assessments
- nutrition focused physical assessment
- functional assessment
- cognitive and psychological function
- socioeconomic and health factors
What to look at with nutrition focused physical assessment
- musculature
- body fat
- mucosa
- hair
- skin
- nails
- eyes
What to look for with a functional assessment
- activities of daily living (ADL) - Activities needed to live life healthy and safe in a dignified way (bathing, washroom, feeding)
- instrumental activities of daily living (IADL) - Things that are great to be independant but are not life requirements (grocery shopping, laundry, managing finances)
- functional measures of muscle mass
Dietary Assessment
- 24-hour recall
- Food records (3-7 days)
- Food frequency questionnaire
- Diet history
Need to consider cognitive decline, remembering 3-7 day food records can be burdensome
Biochemical Assessment
- protein status assessment
- immune function assessment
- serum cholesterol
- vitamin and mineral biomarkers (interest in specific nutrient)
- Also blood samples, urine samples, biological tissue samples
protein status assessments
Usually need to be paired with other measures
* albumin
* transferrin
* prealbumin (transthyretin)
* retinol-binding protein
Immune function assessment
lymphocyte count - immune system is the most responsive organ to changes in nutrition status! T-cell is often used clinically
* C-reactive protein: if suspect infection or underlying inflammation
Why might serum cholesterol by assessed?
hypocholesterolemia occur
late in the course of malnutrition
What is the gold standard for nutritional assessment versus what is used?
Comprehensive assessment is the golden standard (anthropometrics, clinical, dietary and biochemical information) but is high resource intensive (expertise, time, costs), can’t be routine for all older adults so a screening tool is used instead
How do screening tools differ from a comprehensive nutritional assessment?
Is a quick yes and no that can be done rapidly to identify those who may benefit from further evaluation
* standardized methods to identify individuals for follow-up (some tools also assess presence of malnutrition)
* based on factors that are known to be related to nutritional status
* tools need to be reliable and valid
What are the common screening tools used?
- mini nutritional assessmnet (MNA) for older individuals
- Subjective global assessment (PGA) is used in the hospital
Factors Included in Screening and Assessment Tools
- Anthropometrics
- diet intake
- factors that effect food intake
- clinical condition
- social factors
anthropometrics included in the screening tool
- Change in weight (hallmark!!)
- BMI
- Arm or calf circumference
dietary intake measures included in the screening tool
- Change in intake
- Intake/eating frequency
- Intake of certain foods
- Food avoidances
- Fluid intake
- Use of meal replacers
- supplements
- nutrition support
factors that effect food intake included in the screening tool
- Chewing or swallowing problems
- Appetite
- feeling of fullness
- Ability to taste
- Ability to shop and/or cook
- Ability to feed self (TPN?)
- Financial resources
clinical conditions included in the screening tool
- Presence of disease/illness
- GI symptoms
- Medication use (poly-use)
- Motor disability
- Cognitive function
- Psychological stress
social factors included in the screening tool
Thinking beyond the individual
* Living situation
* Eating with others
* Social isolation (one of the biggest risk factors for malnutrition!!)
* Alcohol intake/smoking
Sensitivity and Specificity of Screening and Assessment Tools
Important to balance
* Sensitivity = ability of test to correctly identify those with the disease / condition (malnutrition)
* Specificity = ability of test to correctly identify those who do not have the disease /condition (do not want to overdiagnos)
Flow Diagram for Screening and Assessment
- Population to be tested does screeing test and is separated into negatives (free of condition) postitives (increased risk)
- Positives go through diagnositic procedures and need to correctly capture the individuals with the present condition and intervene and identify those without the condition so as to not overdiagnos
never occurs perfectly
Advantages and disadvantages of MNA and SGA
Screeing and assessment tools
Advantages:
* Identify nutritional risk and diagnosis malnutrition
* High sensitivity and specificity
Disadvantages:
* Requires health professional administration
* more time to complete and higher costs
Components of full MNA
evaluate the risk of malnutrition in older adults and permit early nutritional intervention when needed
* professionally administered and relatively easy to administer and inexpensive
* Has screening section (short form): 6 questions and if no red flags then done & full assessment: screening plus 12 other questions
* based on score: normal nutritional status (high score), at risk of malnutrition, malnourished (low score)
* Self-MNA: screening section completed by older adults, advised to consult health professional if score indicates at risk; further assessment
sensitivity and specificity of MNA
High sensitivity (89-96%) and specificity (94-98%) to detect nutritional risk and diagnose malnutrition
Components of SGA
Assess risk of nutritional complications in clinical population (not just for older adults)
* individuals with medical conditions, hospitalized patients
* professionally administered
* based on assessment: well-nourished (A), mild- moderate undernutrition (B), severe undernutrition (C)
sensitivity and specificity of SGA
high sensitivity (82%) and specificity (72%)
* SGA diagnoses presence of undernutrition but does not detect nutritional risk
* subjective assessment of professionals
What are physical signs to look for with malnutrition?
Will look at specific areas of the body
* eyes can see fat wasting
* triceps wasting (skin without muscle)
* look at ribs
* wasted muscle on forearm
* temple goes inward
* depletion of muscle at shoulders
* edema
* washing of subclavia
* Ulcers on legs
Advantages and disadvantages of short screeing tools
- Advantages: Identify those at risk and need full assessment
- Disadvantages: not diagnostic & equires health professional administration
CNST
Canadian Nutrition Screening Tool (short screening tools) which does screening for nutritional risk in hospitals to identify patients who need SGA/nutrition consult
* professionally administered
* only two questions
* sensitivity 67-73% and specificity 80-86%
What are the 2 questions on the CNST?
- Have you lost weight without trying?
- Have you been eating less than usual?
Advantages and disadvantages of self-admistered tools
Advantages:
* Inexpensive, can screen large number of individuals, and can be utilized during regular check-ups
* Targets community dwelling older adults
* Raises awareness of nutrition risks
Disadvantages:
* Lower sensitivity and specificity, not diagnostic
What is the DETERMINE checklist?
self-administered screening tool targeted to community-dwelling older adults
* used only as a screening and educational tool
* relatively inexpensive
* low sensitivity ~49% and specificity ~64% (using a lower score (total 4 rather than 6) to indicate high nutritional risk improves sensitivity)
What NSI?
Nutritional Screening Initiative which includes two levels of professionally administered assessment based on score, red flag if too high of points
* Level I Screen: anthropometrics (height, weight, BMI); eating habits; living environment; functional status
* Level II Screen: level I screen plus mid-arm circumference; triceps skinfolds; serum albumin, serum cholesterol; drug use information; clinical features; mental/cognitive status
What is SCREEN-II?
Seniors in the Community Risk Evaluation for Eating and Nutrition that is self administered
* self-assessment tool targeted to community- dwelling older adults
* 14 questions about weight, eating habits, factors that affect intake
* administrator calculates score; based on score: low risk, at risk, high risk
* sensitivity ~84% and specificity ~60%
What happens after screening?
older adults identified as at risk for malnutrition should receive a comprehensive nutrition assessment
What are the goals of assessment?
- to confirm the presence of malnutrition and assess its severity
- establish baseline data to evaluate the efficacy of the nutrition therapy provided
Why do we care about Malnutrition?
Higher Mortality
* 44% in malnourished patients vs 18% in well-nourished patients
* 80% in malnourished CHF patients
Increases Length of Hospital Stay
* costs of obesity & overweight are ~1/2 the costs of malnutrition
How do we Identify Older Adults at Risk of Malnutrition?
- nutrition screening: all patients (can be done by patients)
- nutrition assessment: detailed examination looking at whole person
- nutrition intervention will depend on what you find
Potential nutrition intervention strategies
- Alter diet prescription/diet order
- Liberalize diet
- Food fortification
- Provide food/meal preferences
- Recommend vitamin/mineral supplement
- Oral Nutritional Supplements (ONS)
- Enteral Nutrition
- Parenteral Nutrition
Goals of nutrition intervention
- Provide sufficient amounts of energy, protein, and micronutrients
- Maintain or improve: Nutritional status & function, activity, and capacity for rehabilitation & quality of life
- Reduce morbidity and mortality
What factors might influence dietary intake?
