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Slide 1: LINDA GOVERE Click to edit Master subtitle style PENNSYLVANIA STATE UNIVERSITY Nursing 522 11/18/09
Slide 2: Assessment of Nutritional Status in Elderly in LongTerm Care Setting 11/18/09
Slide 3: Objectives • Demonstrate understanding of the physiological changes that affect nutritional status in elderly. To be able to identify assessment tools for assessing nutritional status in elderly. To be able to identify nursing implications related to assessment of nutritional status in elderly. • • 11/18/09
Slide 4: Overview Malnutrition in the elderly • Malnutrition: Any disorder of nutritional status, including disorders resulting from a deficiency of nutrient intake, impaired nutrient metabolism, or over-nutrition. 11/18/09
Slide 5: Overview Cont. • 40% to 60% elderly at risk for malnutrition. 2 - 10% free-living elderly populations 30 - 60% institutionalized elderly 40 - 85% nursing home residents 20 - 60 % home care patients (DiMaria-Ghalili, 2008) 11/18/09 • • • •
Slide 6: Problem of Malnutrition • Malnourished elderly are: – 2 times more likely to visit the doctor 3 times more likely to be hospitalized 2 - 10 times more likely to die if malnourished – • Infection is the most common disorder – • Diminished muscle strength Poor healing • 11/18/09
Slide 7: Changes with aging: – Factors related to inadequate nutrition Physical • • • • diminishing eye sight poor dentition taste changes poor swallowing – – Physiological Metabolic 11/18/09
Slide 8: • Diminished sensory ability Factors related to inadequate nutrition Cont. Less smell perception hard of hearing reduced appetite • General Health Use of drugs Chronic disease and disability 11/18/09
Slide 9: How do we identify elderly at risk for malnutrition? • Nutritional screening – to identify individuals at-risk for malnutrition or who are malnourished to identify early signs of malnutrition and to prevent major problems in organ dysfunction, morbidity and mortality • Nutritional assessment – 11/18/09
Slide 10: Types of screenings and assessments • Subjective Global Assessment Mini-Nutritional Assessment (MNA) Malnutrition Universal Screening Tool (MUST) DETERMINE • • • 11/18/09
Slide 11: Parameters of assessment Subjective Global Assessment (SGA) History • • • • • Weight change Changes in dietary intake Presence of GI symptoms Functional capacity Knowledge of the metabolic demands of the pts underlying disease state 11/18/09
Slide 12: Parameters of assessment Cont. Physical Exam • • • • • Loss of SQ fat Muscle wasting Edema in ankles Edema in sacral area Ascites 11/18/09
Slide 13: Parameters of assessment Cont.  DETERMINE: Disease Eating poorly Tooth loss, mouth pain Economic hardship Reduced social contact 11/18/09
Slide 14: Parameters of assessment Cont. Multiple medicines Involuntary weight loss or gain Need for assistance in self-care Elderly (age > 80) • Scoring: 0–2 = good; 3–5 = moderate nutritional risk; 6 or more = high nutritional risk. 11/18/09
Slide 15: Parameters of assessment Cont. • DETERMINE Developed as part of US Nutritional Screening Initiative check list Self-administered assessment tool • Designed to: Enhance understanding of the nutritional wellbeing Promote consideration of nutritional problems 11/18/09
Slide 16: Parameters of assessment Cont. • The Mini Nutritional Assessment (MNA) Comprises of four parts: Used for older adults anthropometric measurements, general status, diet information and subjective assessment • A score: 11/18/09
Slide 17: Parameters of assessment Cont. maximum score 30 points • • • 24 : < 17 : normal/well-nourished undernutrition 17 - 23.5 : border line/at risk of malnutrition 11/18/09
Slide 18: Parameters of Assessment Cont. • Malnutrition Universal Screening Tool (MUST) Developed by BAPEN Five step screening tool Body mass index (BMI) Unplanned weight loss over 3-6 months Presence of acute diseases Overall risk of malnutrition Management guidelines 11/18/09
Slide 19: Parameters of assessment Cont. – 11/18/09 developed on basis of clinical data
Slide 20: Parameters of assessment Cont. • Allows comparable nutritional screening across different care settings by different health professionals – primary care, home, acute care, long term care • Identifies individuals who are undernourished or obese Not specific for the elderly, but adults • 11/18/09
Slide 21: Case study • Mr. T is an 80 year old male who resides in a long-term care facility. He moved from Oregon a year ago following his son after passing of his wife, Mrs. T. He lives in an independent living and is on zero meal plan, meaning the facility do not provide him with any meals. He cooks at his apartment and he buys his own food. He has declined physically. He has been noted to sleep a lot and skipping meals in his apartment. The house keeping 11/18/09
Slide 22: Case study Cont. • An appointment is made for Mr. T to be seen in health office the following morning. Mr. T does not show up for his appointment . One of the nursing staff goes to check on him and is found sleeping. He pretends nothing is wrong. He appears very pale, tired and very thin. He denies pain but complains of being very tired. He explains that he has not been able to cook or to go for grocery shopping. 11/18/09
Slide 23: Case study Cont. • The DON decides to put Mr. T in an Assistive living to be monitored and evaluated for a couple of days . Further physical assessment reveals pressure ulcer on coccyx area, edema in lower extremities, distended abdomen with hypo-active bowel sounds, cracked lips , very fragile and dry skin and lethargic. Neurological examination indicates short term memory loss, but is otherwise normal. Blood 11/18/09
Slide 24: Case study Cont. Laboratory results reveals BUN 39mg/dl, creatinine 1.8mg/dl, sodium 150mEq/dl, potassium 5.2mEq/dl, albumin 3.0g/dl 11/18/09
Slide 25: The Role of the Health Professional • Action plans in place on how to address the nutritional problems. Use of oral nutritional supplements Input from a dietitian. Consult with pharmacist to review patient's medications for possible drug–nutrient interactions. • • • 11/18/09
Slide 26: The Role of the Health Professional Cont. • Maintain adequate nutritional intake: 30 kcal per kg of body weight and 0.8 to 1g/kg of protein per day, with no more than 30% of calories from fat. Improve oral intake: Mealtime rounds Encourage family members to visit at mealtimes. Ask about and honor patient food preferences. 11/18/09
Slide 27: Small frequent meals with adequate nutrients to help patients regain or maintain weight. Provide nutritious snacks. Help with mouth care and placement of dentures before food is served. The Role of the Health Professional Cont. 11/18/09
Slide 28: The Role of the Health Professional Cont. • Provide conducive environment for meals Remove bedpans, urinals, and emesis basin from room before mealtime Create a more relaxed atmosphere by sitting at the patient’s eye level and making eye contact during feeding. 11/18/09
Slide 29: Order a late food tray or keep food warm if patients are not in their room during mealtime. Do not interrupt patients for round and non-urgent procedures during mealtimes. The Role of the Health Professional Cont. 11/18/09
Slide 30: Patient and caregiver education • How to maintain or improve nutritional status How to administer, when appropriate, oral liquid supplements, enteral tube feeding, or parenteral nutrition. • 11/18/09
Slide 31: Monitoring • Daily weight Assess fluid status with daily weights and strict intake and output. Assess and correct the electrolyte abnormalities • • 11/18/09
Slide 32: Evidence Based Research • Visvanathan R., A Zaiton, M S Sherina, & Y A Muhamad. (2005). The nutritional status of 1081 elderly people residing in publicly funded shelter homes in peninsular Malaysia. European Journal of Clinical Nutrition, 59(3), 318-24 -The aim of this study was to determine the: (1) prevalence of undernutrition as determined by the 'DETERMINE Your Nutritional Health Checklist' 11/18/09
Slide 33: Evidence Based Research • Anthony P. S. (2008). Nutritional screening tools in hospital patients. Parenteral and enteral nutrition (23)4, 373-382. Reviewed 5 types of validated and appropriate nutritional screening and assessment tools that can be used in hospital setting and other settings such as primary care, LTC, acute care, and home care. The tools included: MUST, MNA, SGA, SNAQ, and NRS. 11/18/09
Slide 34: Evidenced Based Research • Tsai , A. C., Tsui-Lan Chang,. Chen, J. T., &TengWen Yang (2009). Population-specific modifications of the short-form Mini Nutritional Assessment and Malnutrition Universal Screening Tool for elderly. Taiwanese. International Journal of Nursing Studies (46)11, 1431-1438. The study was to compare the grading ability of the two scales, and to determine whether adoption of population-specific anthropometric cut-points could improve the grading ability of • 11/18/09
Slide 35: Conclusion • To prevent, minimize & reverse malnutrition in the elderly there needs to be increased identification of nutritional status & appropriate intervention To identify those at risk & who might benefit from intervention the appropriate tool should be used that are inexpensive, practical, simple – • validated for the elderly population 11/18/09
Slide 36: Conclusion Cont. • Research shows that nutritional interventions can be effective in identifying patients who are at risk for malnutrition or who are malnourished There is still need for more research to identify more assessment and screening tools to identify malnutrition in elderly • 11/18/09
Slide 37: References Collier, J. (2009) Under nutrition in the elderly. Retrieved from http:// www.dietetics.co.uk/article-undernutrition-in-the-el DiMaria-Ghalili, R. A., (2008). Nutrition in the elderly nursing standard of practice protocol: Nutrition in aging. Retrieved from http://consultgerirn.org/topics/nutrition_in_the_eld 11/18/09
Slide 38: References Cont. Soini, H., Routasalo, P., & Lagström, H. (2004). Characteristics of the Mini-Nutritional Assessment in elderly home-care patients. European Journal of Clinical Nutrition (58) 64– 70. http://www.nature.com.ezaccess.libraries.psu.edu/e 11/18/09