Nutrition Mission

The Hospitalist. 2008 January;2008(01):

January 1, 2008 | The Hospitalist

Has food intake decreased recently?
Are there physical difficulties with eating?
Is the patient confused or depressed?
Has there been diarrhea or vomiting?
Has the patient been able to shop and manage food preparation?
Has the patient or family noticed weight loss?
What does the patient regard as a normal weight?

However, because the clinical signs of malnutrition-weight loss, muscle wasting, and fatigue can be difficult to detect from history alone, use of an assessment tool is often necessary.

There is no simple diagnostic test for undernutrition. Measurements of albumin, prealbumin, body-mass index (BMI), and weight loss have been used, albeit problematically, for this purpose. More useful for the quantification of nutritional status in elderly outpatients, these measurements are difficult to use in the hospital because albumin levels are frequently affected by disease processes involving the liver, kidney, and immune system, and correct baseline weights and heights are notoriously difficult to obtain from elderly patients.4

The Nutritional Risk Index was developed in response to these difficulties, but it was originally calibrated for young, post-surgical patients. Because of the problematic nature of obtaining the accurate heights and weights needed for the NRI in elderly patients, Bouillanne, et al,. developed the Geriatric Nutritional Risk Index (GNRI) in 2005 based on albumin levels, hospital recorded weights, and weight loss (see Table 1, above).

The GNRI’s creators classified patients according to their level of malnutrition and calculated their risk of related comorbidities. They found that 44% of their study population had major or moderate nutrition-related risk and recommended nutritional supplementation.

Practical Intervention

Prevention: Assess your patient’s nutritional status. Alcoholism, tooth loss, and functional disabilities are only a few of the predisposing factors for nutrient loss in the prehospitalized patient. Obesity does not protect against a compromised nutrient state. Use an assessment tool designed for elderly patients. Measurements of weight loss and albumin do not effectively correlate with adverse outcomes in elderly patients.
Monitor what your patients eat: The attending healthcare team is the first line of defense against the development of nutritional problems. Make sure they are accurately assessing patients’ intake.
Discontinue medications that interfere with appetite, salivation, and attention: Overmedication poses a serious threat to patients who have difficulty eating, particularly those with dementia. Additionally, avoid appetite stimulants, such as megestrol acetate.
Modify food and feeding routine to suit individuals needs: Special foods, customized feeding times, and feeding assistance (particularly from someone accustomed to feeding the patient) may increase oral intake and negate the need for supplementation.
Discuss the risks and benefits of a feeding tube with the patient and patient’s family before intervening: Feeding tubes have not been shown to reduce the risk of aspiration pneumonia, infections, or pressure ulcers. The one-year survival rate for patients after receiving a feeding tube is approximately 40%. Whether the placement of a feeding tube makes patients more comfortable or improves their quality of life is difficult to prove. In discussing whether to place a feeding tube, educate the patient’s family and get a clear understanding of their motivations and goals before proceeding.—JL

Path to Recovery

Refeeding regimens for elderly patients diagnosed as undernourished are best started with meals of personally chosen foods, timed for when patients are hungry.

Many elderly patients do not eat on a strict schedule at home and have difficulty complying with such a schedule. If oral intake remains inadequate, offer nutritional supplements. Because low-energy diets are usually low in vitamins and minerals, supplementation with a multivitamin, thiamine, folic acid, and zinc can be beneficial.