Studies suggest that up to 85% of long term care patients suffer from some level of malnutrition. Finding the balance between providing adequate nutrition and hydration can be especially challenging in the elderly population, specifically when dealing with obstacles such as medical diagnosis, food preferences and honoring advanced directives.
The definition of malnutrition is currently under review. Current studies indicate that abnormal albumin levels do not necessarily indicate malnutrition; rather, it is a compilation of symptoms including weight loss, loss of muscle mass, loss of subcutaneous fat tissue and diminished functional status. Two or three of these symptoms indicate clinical malnutrition. Clinical malnutrition can have a significant impact on wound healing. When the body loses lean body mass there is an adverse effect on muscles, water content, bone, minerals, protein and the body’s organs. These are the key components that keep the body functioning and allow it to fight off infection and heal.
There is an easy formula to determine a patient’s malnutrition risk when utilizing the right tool. This tool is called the “Malnutrition Universal Screening Tool” (www.bapen.org.uk):
- Step 1 – Obtain the BMI score
- BMI of:
- Greater than 20 = 0 points
- 18.5–20 = 1 point
- Less than 18.5 = 2 points
- Step 2 – Obtain the weight loss score
- Unplanned weight loss of:
- Less than 5% = 0 points
- 5–10% = 1 point
- Greater than 10% = 2 points
- Step 3 – Obtain acute disease effect score
- If patient is acutely ill and there has been or is likely to be no nutritional intake for greater than 5 days = 2 points
- Step 4 – Add these numbers together.
- A score of 0 = low risk for malnutrition
- A score of 1 = medium risk
- A score of 2 or greater = high risk for malnutrition.
To manage malnutrition risk, complete a three day intake study to determine actual nutritional intake trends. Dietary intake and care plans should be adjusted to meet the individual needs of the patient based on the risks identified. A comprehensive review of the patient’s nutritional trends may reveal that patients avoid certain textures of food. This could be an indicator that the patient may benefit clinically from a dysphagia evaluation or an Occupational Therapy evaluation to rule out if dysphagia or feeding difficulties may be contributing to poor intake and or weight loss. Swallowing deficits and feeding impairments can be difficult to identify when a patient’s intake is limited.
Consequences of untreated malnutrition can include delayed wound healing, increased recovery time, decreased muscle mass impacting physical functioning and mobility as well as an increased risk for infections. These clinical complications not only can result in negative clinical outcomes but can increase health care costs.
A key component to promoting wound healing is to increase daily carbohydrate intake to 30-35 grams per Kilogram of body weight. A second critical component is increasing daily protein intake. Daily protein requirements of 1.2 to 1.5 grams per Kilogram of body weight are typically recommended to promote optimal wound healing. The 2009 NPUAP White Paper “The Role of Nutrition in Pressure Ulcer Prevention and Treatment” states “ changes in albumin, prealbumin or transferrin levels should not be used to suggest changes in protein status in individuals with acute or chronic inflammatory states”. These changes are more indicative of the inflammatory process rather than nutritional status. Examples of the impairments which will affect these levels include: infections, cancer, liver failure, dehydration, stress and prolonged bed rest. Studies indicate that the levels of these blood tests correlate more with the severity of the underlying disease rather than nutritional status. The Dietician should assess all aspects of the patient condition when developing an individualized nutritional plan of care. The role of the Dietician in promoting wound healing and pressure ulcer prevention is as important as the role of the nurse providing the daily treatment. Early identification of malnutrition risk and identifying acute malnutrition is the key to success.
- Collins N, and Sloan C. Nutrition 411: Back to Basics: Nutrition as part of overall wound treatment plan, Ostomy Wound Management, Volume 59, Issue 4 April 2013
- Fuhrman MP, et al. Hepatic Proteins and Nutritional Assessment. Journal of American Dietetic Association. 2004; 104:1258–1264
- Malnutrition Universal Screening Tool by MAG Malnutrition Advisory Group