Abstract: Although clinical pathways are most often developed for very narrow diagnoses with limited pharmaceutical treatments, they are even more needed to provide direction for symptom management involving multiple diagnoses, with myriad pharmaceutical and nonpharmaceutical treatments—such as malnutrition management. A clinical pathway model for malnutrition management can be applied across many systems, such as in long-term care facilities and integrated delivery systems. Its application within these health systems offer the best opportunities for improved clinical and economic outcomes.
Involuntary weight loss as a result of malnutrition is a major problem among elderly patients residing in long-term care facilities (LTCFs). Malnutrition is defined as a deficiency of calorie, protein, or other nutrients that result in adverse outcomes on body function, body form, or clinical outcome.1 Estimates of malnutrition prevalence in the LTCFs range from 1.5% to 66.5%, due to variable assessment methods.2 Various parameters and cutoff values are used for nutritional assessment, with no expert consensus agreement.3 The Joint Commission requires screening for malnutrition of hospitalized patients,4 and federal guidelines recommend nursing homes reassess patient nutritional status given an unplanned weight loss of 5% or more in 1 month, 7.5% or more in 3 months, or 10% or more in 6 months.5 However, there is no mandate recommending a standardized screening tool, anthropometric assessment, or biochemical markers.
Malnutrition prevalence may have a direct impact on the risk adjustment of LTCFs outcome indicators, health care resource utilization, and financial outcomes for facilities. Elderly patients with malnutrition have been shown to experience more hospitalizations, longer lengths of stay, and higher cost of care.6 LTCFs may properly adjust outcome indicators based on malnutrition prevalence. For example, the elderly malnourished patient is more likely to develop pressure ulcers,6 which is an outcome indicator. Accurately documenting malnutrition may account for differences in the risk for adverse outcomes, which have financial implications to LTCFs.7 Accurate prevention and diagnoses of malnutrition is important for patient outcomes and LTCFs resource utilization.
Risk Factors for Malnutrition
Risk factors for malnutrition in the elderly can be broadly categorized into three main types: medical, social, and psychological.8 Aging does not lead to malnutrition, but the changes associated with aging can increase the risk for malnutrition, as presented in Table 1.9 Many chronic diseases contribute to inflammation that can lead to significant loss of muscle mass and malnutrition.10 Restrictive meal plans such as low salt, diabetic, and low cholesterol diets have also been shown to contribute to malnutrition in the elderly.11
A recent systematic review of the literature found the significant risk factors for malnutrition in the elderly included age; frailty in institutionalized persons; excessive polypharmacy; general health decline, including physical function; Parkinson disease; constipation; poor or moderate self-reported health status; cognitive decline; dementia; eating dependencies; loss of interest in life; poor appetite; basal oral dysphagia; signs of impaired efficacy of swallowing; and institutionalization.12
Diagnostic Criteria for Malnutrition
Variable definitions of malnutrition in the past have made diagnosis challenging. The Academy of Nutrition and Dietetics and the American Society for Parenteral and Enteral Nutrition endeavored to define malnutrition, and in 2012 outlined characteristics to define three broad categories of malnutrition.2 The characteristics of malnutrition are presented in Table 2. A minimum of two of the six characteristics above is recommended for diagnosis of either severe or nonsevere malnutrition.
Metabolic stress and inflammation accompany severe acute illness and trauma, which may lead to malnutrition status in the elderly.2,10 Chronic illness also creates a systemic inflammatory response, which may lead to malnutrition. Social or environmental factors, such as restrictive diets or limited access to food, leads to malnutrition from energy deficiency without inflammation.2,11
Malnutrition Universal Screening Tool
The Malnutrition Universal Screening Tool (MUST) is the recommended screening tool by the National Institute of Clinical Excellence, the British Association for Parenteral and Enteral and Nutrition, and the British Dietitian Association. MUST is a five-step screening tool, which takes about 5 minutes to complete and helps identify elderly patients who are malnourished or at risk for becoming malnourished. The components of the questionnaire include body mass index (BMI), unexplained weight loss, and acute illness history.
Clinical Assessment
Obtaining a careful history may reveal a cause for malnutrition. A medical history of cancer, infectious disease, diabetes mellitus, congestive heart failure, pulmonary disease, and mental illness should be evaluated as a contributing factor for malnutrition.13 Certain medications can also cause malnutrition, as detailed in Table 3.
The examination findings of a malnourished patient may include a thin-appearing patient with skeletal muscle loss, subcutaneous fat loss, dry and scaling skin, edema, dry and brittle hair, poor healing ulcers, and spooned and depigmented nails.
Physical exam should assess muscle wasting of the temporalis, pectoralis major, deltoid, trapezius, supraspinus, infraspinus, interosseous muscles of the dorsal hand, quadricep, and gastrocnemius muscle (Table 4).14
Anthropometric Assessment
Anthropometric measurements are numerical assessments of the size, shape, and composition of the body. Measurements such as BMI, as well as skinfold measurements, such as calf circumference, mid-upper arm circumference, and triceps skinfold thickness provide a numerical evaluation of nutritional status. BMI is categorized by the World Health Organization, where underweight is a BMI < 18.5; normal is 18.5 to 24.9; overweight is 25 to 29.9; obese is 30 to 39.9; and extreme obesity is > 40.15 Comparison of assessed BMI vs ideal BMI is helpful for assessing malnutrition, but should be used with caution. BMI in elderly patients may be misleading, due to height loss from change in posture, curvature of the spine, edema, and underlying medical conditions.13 Skinfold measurements are helpful indicators and independent predictors of mortality in elderly patients living in LTCFs.16 Anthropometric measurements should be used with caution and in consideration of confounding or underlying medical conditions that may result in an erroneous malnutrition conclusion.
Assessment Tools
Mini Nutritional Assessment
The Mini Nutritional Assessment (MNA) is the most widespread tool for nutritional screening and assessment, due to the ease of use and the feasibility in any clinical care setting.17 The importance of this tool increases, as with aging we see an increased reduction in muscle mass and loss of metabolically active components, which leads to a loss of functionality.17 Extensive reviews and analysis of the MNA have been performed and due to its design, its ease, and the timely manner in which it can be used, as well as its reliability, it is appropriate for decision making and guiding nutritional intervention.17,18 Two potential limitations have been raised in recent research regarding the MNA, which include the time required for completion, and who should complete the tool. Both of these issues have been resolved by the development of the MNA-SF (short form), and suggesting this tool to be completed by the nursing staff or caregiver. In some cases, the MNA should be integrated with other tools needed to evaluate patients malnourished or at risk; identify patients at risk of developing nutrition related complications; and identifying patients who can benefit from nutritional intervention.17
The MNA-SF provides a quick and simple method of identifying older patients at risk for malnutrition. Minimal time is needed to complete the MNA-SF. Calf circumference has been shown effective in place of BMI when using the MNA-SF for accurate assessment of a bedridden patient for malnutrition.
Biochemical Markers
Biochemical markers have been used in the past to evaluate malnutrition; however, they are now hardly used in clinical practice. It is important to note that the following markers that will be mentioned should be used with caution in determining a patient’s malnutrition status. Serum albumin is the most common biochemical marker used to assess visceral protein stores. Independent of disease, serum albumin predicts mortality in the elderly.19 Serum albumin can be used to assess baseline nutritional status and degree of malnutrition, but should be used with caution. Studies demonstrate serum albumin decreases with age.19 Underlying medical conditions can decrease serum albumin levels, including liver disease, inflammation, and infection. This limits serum albumin as an indicator of malnutrition, especially in the acutely or chronically ill. In addition, the long half-life of albumin does not allow for monitoring short term changes in protein and energy intake.19 For these reasons, serum albumin is not considered a reliable measure.
Decreased cholesterol levels from baseline may also indicate malnutrition from inadequate caloric intake, and has been shown to be a predictor of mortality in elderly individuals living in LTCFs.13 Transferrin and prealbumin are not routinely used in practice to measure nutritional status because of low specificity, but are more sensitive of early protein malnutrition than albumin.19 Assessment of micronutrients should also be considered because deficiencies can cause various medical conditions (Table 5).20 Specific nutritional deficiencies are associated with specific clinical signs. Since biochemical markers have great variability in terms of reliability and accuracy, it is recommended that they be used with caution if being used to assess malnutrition in the elderly.
Prevention of Malnutrition
The prevention of malnutrition in elderly people not only will benefit the health of LTCF residents, but can relieve a financial burden that would increase once malnutrition is already in place.21 For malnourished elderly patients, it has been shown that counseling is an effective method to improving dietary habits,22 thus reducing further progression of malnutrition. According to the 2015 Dietary Guidelines for Americans, elderly males living a sedentary lifestyle, such as those in LTCFs, require 2000 calories daily; 1600 calories is the appropriate intake for elderly females.23 The US Department of Agriculture provides a breakdown of the recommended daily food intake as shown in Table 6.
Another method to ensure adequate nutrition among elderly patients is to identify those whose daily caloric intake is fewer than 1500 calories per day; advise patients about nutrient-dense food choices when appropriate; investigate body weight losses of 4% or more; supplement at risk and frail elderly patients for fractures; educate patients on the merits of whole grains, fruits, and vegetables; and consider referral to other health professionals for nutritional advice (dieticians, speech and language pathologist, home care or visiting nurse services, or other specialized geriatric services available in the community).24 Nursing staff are helpful in assessing the nutritional needs of residents in LTCFs, and are able to identify earlier patients whose needs are unmet by their current nutritional status.25
Treatment of Malnutrition
It is necessary to raise awareness with the elderly and their caregivers about the quality, quantity, and frequency of food intake in older persons.26 A multidimensional approach is required to deal with these issues, including a referral to a clinical dietician or nurse educator following general dietary advice from a physician.26,27 Efforts should be initiated to help the elderly maintain or improve their functional status.26 Changes in the body metabolism due to acute or chronic diseases, and sometimes treatment interventions, increase the daily nutritional needs of the elderly.20 Multiple studies24,28-29 recommend correcting the underlying causes of malnutrition, whether it be medical, social, or psychological, as listed in Table 1. Enlisting aid from various health professionals will be able to determine the best correction method for the malnourished.24,26 Medications should not be considered as first-line therapy for treatment of malnutrition in the elderly population.
A variety of nutritional supplement exist to treat malnutrition as listed in Table 7.
An often overlooked problem associated with malnutrition in elderly patients in LTCFs is dehydration.32 Elderly individuals often either do not know or are unable to express that they are thirsty. Nurses and other staff in LTCFs can manage dehydration by making “fluid rounds” to ensure constant hydration.32 Combining the services of dieticians, speech therapists, and social services cannot be overlooked, as many of these providers have techniques which may help with malnutrition. One study found that caloric intake was greater in patients who receive both nutritional supplements and exercise than in patients who only receive supplements.33
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