BACKGROUND/STATEMENT OF PROBLEM

A.  Definition(s)

1. Malnutrition: Any disorder of nutritional status, including disorders resulting from a deficiency of nutrient intake, impaired nutrient metabolism, or overnutrition

B.  Etiology and/or epidemiology: Older adults are at risk for undernutrition because of dietary, economic, psychosocial, and physiological factors (DiMaria-Ghalili & Amella, 2005).

1. Dietary intake
   • Little or no appetite (Carlsson et al., 2005; Ramic et al., 2011)
   • Problems with eating or swallowing (Serra-Prat et al., 2012)
   • Eating inadequate servings of nutrients (Ramic et al., 2011)
   • Eating fewer than two meals a day (Ramic et al., 2011)
2. Limited income may cause restriction in the number of meals eaten per day or dietary quality of meals eaten (Samuel et al., 2012).
3. Isolation
   • Older adults who live alone may lose desire to cook because of loneliness (Ramic et al., 2011; Stroebe et al., 2007)
   • Appetite of widows decreases (DiGiacomo, Lewis, Nolan, Phillips, & Davidson, 2013)
   • Difficulty cooking because of disabilities (Anyanwu et al., 2011)
   • Lack of access to transportation to buy food (DiMaria-Ghalili & Amella, 2005)
4. Chronic illness
   • Chronic conditions can affect intake (DiMaria-Ghalili, 2014).
   • Disability can hinder ability to prepare or ingest food (Anyanwu et al., 2011; Litchford, 2014).
   • Depression can cause decreased appetite (Engel et al., 2011).
   • Poor oral health (cavities, gum disease, and missing teeth), and xerostomia, or dry mouth, impairs ability to lubricate, masticate, and swallow food (Palacios & Joshipura, 2015).
   • Antidepressants, antihypertensives, and bronchodilators can contribute to xerostomia (DiMaria-Ghalili & Amella, 2005).
5. Physiological changes
   • Decrease in lean body mass and redistribution of fat around internal organs lead to decreased caloric requirements (Janssen, Heymsfield, Allison, et al., 2002)
   • Change in taste (from medications, nutrient deficiencies, or taste bud atrophy) can also alter nutritional status (DiMaria-Ghalili & Amella, 2005)

PARAMETERS OF ASSESSMENT

A.  General: During routine nursing assessment, any alterations in general assessment parameters that influence intake, absorption, or digestion of nutrients should be further assessed to determine whether the older adult is at nutritional risk. These parameters include:

1. General assessment, including present history, assessment of symptoms, past medical and surgical history, and comorbidities (DiMaria-Ghalili, 2014)
2. Social history (DiMaria-Ghalili, 2014)
3. Drug–nutrient interactions: Drugs can modify the nutrient needs and metabolism of older people. Restrictive diets, malnutrition, changes in eating patterns, alcoholism, and chronic disease with long-term drug treatment are some of the risk factors in older adults that place them at risk for drug–nutrient interactions (DiMaria-Ghalili, 2014)
4. Functional limitations (DiMaria-Ghalili, 2014)
5. Psychological status (DiMaria-Ghalili, 2014)
6. Physical assessment: Physical examination with emphasis on oral examination (see Chapter 11, Oral Healthcare in the Older Adult); loss of subcutaneous fat, muscle wasting, and BMI (DiMaria-Ghalili, 2014); and dysphagia

B.  Dietary intake: In-depth assessment of dietary intake during hospitalization may be documented with a dietary intake analysis (calorie count; DiMaria-Ghalili & Amella, 2005).

C.  Risk assessment tool: The MNA should be performed to determine whether an older hospitalized patient is either at risk of malnutrition or has malnutrition. The MNA determines risk based on food intake, mobility, BMI, history of weight loss, psychological stress, or acute disease, and dementia or other psychological conditions. If score on the MNA-SF is 11 points or less, the in-depth MNA assessment should be performed (DiMaria-Ghalili & Guenter, 2008). See the “Resources” section or go to consultgerirn.org/resources for nutrition information.

D.  Anthropometry

1. Obtain an accurate weight and height through direct measurement. Do not rely on patient recall. If the patient cannot stand erect to measure height, then either a demi-span measurement or a knee-height measurement should be taken to estimate height using special knee-height calipers (DiMaria-Ghalili & Amella, 2005). Height should never be estimated or recalled because of shortening of the spine with advanced age; self-reported height may be off by as much as 2.4 cm (DiMaria-Ghalili & Amella, 2005).
2. Weight history: A detailed weight history should be obtained along with current weight. Detailed weight history should include a history of weight loss, whether the weight loss was intentional or unintentional, and during what period. A loss of 10 pounds over a 6-month period, whether intentional or unintentional, is a critical indicator for further assessment (DiMaria-Ghalili & Amella, 2005).
3. Calculate BMI to determine whether weight for height is within normal range: 23 to 30. A BMI below 23 is a sign of undernutrition (Centers for Medicare & Medicaid Services, 2019).

E.  Visceral proteins: Serum albumin, transferrin, and prealbumin are visceral proteins traditionally used to assess and monitor nutritional status (DiMaria-Ghalili & Amella, 2005). However, keep in mind that these proteins are negative acute-phase reactants, so during a stress state, the production is usually decreased. In the older hospitalized patient, albumin levels may be a better indicator of prognosis than nutritional status (White et al., 2012). Consider using inflammatory markers (C-reactive protein or interleukin-6) to ascertain whether the changes in albumin are caused by nutritional alterations or an inflammatory state (Jensen et al., 2012; Jensen & Wheeler, 2012).

F.   Functional status: Measure handgrip strength using a hand dynamometer (White et al., 2012); review ability to perform ADL and IADL (DiMaria-Ghalili, 2014).

G.  Transitional care needs determine the ability of the patient to shop, cook, and feed self after discharge (DiMaria-Ghalili, 2014).

NURSING CARE STRATEGIES

A.  Collaboration (DiMaria-Ghalili & Amella, 2005)

1. Refer to a dietitian if the patient is at risk of undernutrition or has undernutrition.
2. Consult with a pharmacist to review the patient’s medications for possible drug–nutrient interactions.
3. Consult with a multidisciplinary team specializing in nutrition.
4. Consult with a social worker, an occupational therapist, and a speech therapist as appropriate.

B.  Alleviate dry mouth

1. Avoid caffeine; alcohol and tobacco; and dry, bulk, spicy, salty, or highly acidic foods.
2. If the patient does not have dementia or swallowing difficulties, offer sugarless hard candy or chewing gum to stimulate saliva.
3. Keep lips moist with petroleum jelly.
4. Take frequent sips of water.

C.  Maintain adequate nutritional intake

Daily requirements for healthy older adults include 30 kcal/kg of body weight, and 1 to 1.2 g/kg of protein per day (Bauer et al., 2013), with no more than 30% of calories from fat. Caloric, carbohydrate, protein, and fat requirements may differ depending on degree of malnutrition and physiological stress.

D.  Improve oral intake

1. Assess each patient’s ability to eat within 24 hours of admission (Jefferies, Johnson, & Ravens, 2011).
2. Engage in mealtime rounds to determine how much food is consumed and whether assistance is needed (Jefferies et al., 2011).
3. Limit staff breaks to before or after patient mealtimes to ensure that adequate staff are available to help with meals (Jefferies et al., 2011).
4. Encourage family members to visit at mealtimes.
5. Ask family to bring favorite foods from home when appropriate.
6. Ask about patient food preferences and honor them.
7. Suggest small, frequent meals with adequate nutrients to help patients regain or maintain weight (Joanna Briggs Institute, 2007).
8. Provide nutritious snacks (Joanna Briggs Institute, 2007).
9. Help patient with mouth care and placement of dentures before food is served (Jefferies et al., 2011).

E.  Provide conducive environment for meals

1. Remove bedpans, urinals, and emesis basins from rooms before mealtime.
2. Administer analgesics and antiemetics on a schedule that will diminish the likelihood of pain or nausea during mealtimes.
3. Serve meals to patients in a chair if they can get out of bed and remain seated.
4. Create a more relaxed atmosphere by sitting at the patient’s eye level and making eye contact during feeding.
5. Order a late food tray or keep food warm if the patients are not in their rooms during mealtimes.
6. Do not interrupt patients for round and nonurgent procedures during mealtimes.

F.   Specialized nutritional support (Sobotka et al., 2009; Ukleja et al., 2018; Volkert et al., 2019)

1. Start specialized nutritional support when a patient cannot, should not, or will not eat adequately and if the benefits of nutrition outweigh the associated risks.
2. Before initiation of specialized nutritional support, review the patient’s advance directives regarding the use of artificial nutrition and hydration.

G.  Provide oral supplements

1. Supplements should not replace meals but should be provided between meals and not within the hour preceding a meal and at bedtime (Joanna Briggs Institute, 2007; Wilson et al., 2002).
2. Ensure that oral supplement is at the appropriate temperature (Joanna Briggs Institute, 2007).
3. Ensure that the patient can open oral supplement packaging (Joanna Briggs Institute, 2007).
4. Monitor the intake of the prescribed supplement (Joanna Briggs Institute, 2007).
5. Promote a sip style of supplement consumption (Joanna Briggs Institute, 2007).
6. Include supplements as part of the medication protocol (Joanna Briggs Institute, 2007).

H.  NPO orders

1. Schedule older adults for tests or procedures early in the day to decrease the length of time they are not allowed to eat and drink.
2. If testing late in the day is inevitable, ask the physician whether the patient can have an early breakfast.
3. See ASA practice guideline regarding recommended length of time patients should be kept NPO for elective surgical procedures.

EVALUATION/EXPECTED OUTCOMES

A.  Patient will

1. Experience improvement in indicators of nutritional status.
2. Improve functional status and general well-being.

B.  Provider should

1. Ensure that care includes food and fluid of adequate quantity and quality in an environment conducive to eating, with appropriate support (e.g., modified eating aids) for people who can potentially chew and swallow but are unable to feed themselves.
2. Continue to reassess patients who are malnourished or at risk for malnutrition.
3. Monitor for refeeding syndrome.

C.  Institution will

1. Ensure that all healthcare professionals who are directly involved in patient care should receive education and training on the importance of providing adequate nutrition.

D.  QA/QI

1. Establish QA/QI measures surrounding nutritional management in aging patients.

E.  Educational

1. Provided education and training includes
   • Nutritional needs and indications for nutrition support
   • Options for nutrition support (oral, enteral, and parenteral)
   • Ethical and legal concepts
   • Potential risks and benefits
   • When and where to seek expert advice
2. Patient and/or caregiver education includes how to maintain or improve nutritional status as well as how to administer, when appropriate, oral liquid supplements, enteral tube feeding, or parenteral nutrition.

FOLLOW-UP MONITORING

A.  Monitor for gradual increase in weight over time.

1. Weigh patient weekly to monitor trends in weight.
2. Daily weights are useful for monitoring fluid status.

B.  Monitor and assess for refeeding syndrome (Skipper, 2012).

1. Carefully monitor and assess patients the first week of aggressive nutritional repletion.
2. Assess and correct the following electrolyte abnormalities: hypophosphatemia, hypokalemia, hypomagnesemia, hyperglycemia, and hypoglycemia.
3. Assess fluid status with daily weights and strict intake and output.
4. Assess for congestive heart failure in patients with respiratory or cardiac difficulties.
5. Ensure caloric goals will be reached slowly, over more than 3 to 4 days, to avoid refeeding syndrome when repletion of nutritional status is warranted.
6. Be aware that refeeding syndrome is not only exclusive to patients started on aggressive artificial nutrition, but may also be found in older adults with chronic comorbid medical conditions and poor nutrient intake started with aggressive nutritional repletion via oral intake.

RELEVANT GUIDELINES

A.  Preoperative nutrition assessment

1. American Geriatrics Society (2012)

B.  Preoperative fasting

1. American Society of Anesthesiologists (2017)
2. Lambert and Carey (2015)

C.  Nutrition interventions

1. Bauer et al. (2013)
2. Sobotka et al. (2009)
3. Ukleja et al. (2018)
4. Volkert et al. (2019)

 

ABBREVIATIONS

ACS            American College of Surgeons

ADL            Activities of daily living

AGS            American Geriatrics Society

ASA            American Society of Anesthesiologists

BMI             Body mass index

IAD             Instrumental activities of daily living

MNA           Mini Nutritional Assessment

NPO            Nothing by mouth

NSQIP        National Surgical Quality Improvement Program

QA/QI         Quality assurance/quality improvement

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Updated: November 2020

Boltz PhD, RN, GNP-BC, FGSA, FAAN, M., Capezuti PhD, RN, FAAN, E., Zwicker DrNP, APRN, BC, D., & Fulmer PhD, RN, FAAN, T. T. (2020). Evidence-Based Geriatric Nursing Protocols for Best Practice (6th ed.). Springer Publishing. Retrieved November 4, 2020, from https://www.springerpub.com/evidence-based-geriatric-nursing-protocols-for-best-practice-9780826188144.html#description

Chapter 13:  DiMaria-Ghalili, R. (2021) Nutrition in the Older Adult. In M. Boltz, E. Capezuti, D. Zwicker & T. Fulmer (eds.).  Evidence-Based Geriatric Nursing Protocols for Best Practice (6th ed. pp 179-190).  New York: Springer.