Malnutrition used to be an unknown, or a “skeleton in the hospital closet” per 1974 article that found several instances of nutritional neglect in hospitals by physicians (1).   Butterworth pointed out that changes in practice were urgently needed to properly identify and treat undernourished patients (1).  In the past 40 years, nutrition information has changed significantly right along with medicine.    Studies continue to show that malnutrition increases the length of stay in hospitals, increases the risk of readmission, and increases overall mortality (2).  As a medical profession, we are having a difficult time coming to a consensus on how to define malnutrition, and what are its indicators.   As of 2012, the Academy of Nutrition and Dietetics (Academy) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) do not recommended using inflammatory biomarkers such as serum protein levels for diagnosis of malnutrition (3).   “Adult undernutrition typically occurs along a continuum of inadequate intake and/or increased requirements, impaired absorption, altered transport, and altered nutrient utilization,” states the Academy and A.S.P.E.N. (3)

Is malnutrition and identification an issue for the dietitian and that’s it?  No, says Martie Moore RN, MAOM, it should be everyone’s issue (4).  Malnutrition is multi-factorial.   Socio-economics, dentition, pain, constipation, malabsorption, nausea, cognition, mental health are just a few examples what may influence someone’s nutritional status.     In a Canadian survey, physicians didn’t feel like they had the knowledge to identify malnutrition, and they desire a team approach (5).   It takes a team approach to identify residents at risk, determine cause of the nutritional issue, and the best intervention.  Then, it takes a team to take the plan into action.

Look at the practice within your own facility.  Are you still using protein serum levels to determine malnutrition? (4)  Do CNAs communicate to dietitian or nursing that most of the resident’s meal ends up in his lap due to tremors?  Is the pharmacist informing nursing or dietary that the new medication may cause a sore mouth?   We can create a great team with the resident as our focus (6), between doctor, dietitian, nutrition department, nurse, CNA, speech therapy, occupational therapy, and dentist.

One study shows cognitively-impaired and total assist residents received the most benefit from an increase in number of CNAs with dedicated meal roles (7).  The other intervention that also increase caloric intake for all, was “protected meal times” not allowing interruptions at meals for common things like therapy, doctor visits, lab draws, etc. (7).   Do we need to think out of the box of traditional job roles to best meet our residents’ needs?   Should management assist with meal service and setup our elders, allowing our licensed staff to assist residents that need to be fed at meals?  Mildred may want additional gravy on her pork, or Leroy likes two butters on his roll.  These little additions may make that meal exceptional, or easier to swallow, and allow for 75% meal intake.  They also add calories!

Nutritional supplements are not always the answer to malnutrition, wounds, or poor oral intake, especially if they don’t taste good to the resident.   Have the team do a taste test of supplements to know what they taste like and be knowledgeable of types facility provides.   It’s amazing how much good a simple intervention like a snack of whole milk and cookies, or juice and half a sandwich.  Personalization is the name of the game.  Someone that worked for 40 years on night shift, may desire to eat snacks or small meals at night, especially if dementia is a factor.  Get know your residents, collaborate with your team, and develop a plan to beat malnutrition.  Let’s GO!

 

References

  1. Butterworth, C.E. Jr. The skeleton in the hospital closet. 1974. Nutrition Today: 2 (1974): 4-8.
  2. Lim, Su Lin, et al. “Malnutrition and its impact on cost of hospitalization, length of stay, readmission and 3-year mortality.” Clinical nutrition 31.3 (2012): 345-350.
  3. White JW, et al. Academy of Nutrition and Dietetics Malnutrition Work Group; A.S.P.E.N. Malnutrition Task Force; A.S.P.E.N. Board of Directors. Consensus Statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition. J Acad Nutr Diet 112 (2012): 730–8.
  4. Moore, M. “Malnourishment: your issue and mine.”  McKnight’s LTC News. April 26, 2017.  http://www.mcknights.com/guest-columns/malnourishment-your-issue-and-mine.
  5. Duerksen, DR., et al. “Physicians’ perceptions regarding the detection and management of malnutrition in Canadian hospitals: results of a Canadian Malnutrition Task Force Survey.” Journal of Parenteral and Enteral Nutrition 39.4 (2015): 410-417.
  6. Posthauer ME, et al. Nutritional Strategies for Pressure Ulcer Management. In: Krasner DL, ed. Chronic Wound Care: The Essentials: A Clinical Source Book for Healthcare Professionals. Malvern, PA: HMP Communications LLC; 2014.
  7. Young, AM., et al. “Encouraging, assisting and time to EAT: improved nutritional intake for older medical patients receiving protected mealtimes and/or additional nursing feeding assistance.” Clinical nutrition 32.4 (2013): 543-549.