The incidence and impact of malnutrition in older people is underestimated. The best option for treating malnutrition is to enhance normal eating and drinking. A “Food First” approach encourages eating frequent, small, high energy and protein meals and snacks. Nutritional supplements for weight gain are generally not required unless body weight is unable to be maintained with a normal balanced diet, or if food cannot be eaten safely. Show
View / Download pdf version of this article Key concepts
Changes to the funding of oral nutritional supplementsPHARMAC has recently made a number of changes to the access and funding of oral nutritional supplements, including powders for reconstitution and ready-made liquids. These changes include:
Background to the recent funding changes In New Zealand, use of ready-made liquid supplements has been increasing steadily. Expenditure on standard adult oral and enteral products was $6.7 million in 2008/09 with annual growth of 13%. Of this, $5.7 million was for ready-made liquids, e.g. Ensure Plus and Fortisip (see graph Allergy to cows’ milk protein and the appropriate use of infant formula). In the United Kingdom there has been concern regarding the treatment approach to malnutrition in elderly people. This has resulted in the formulation of treatment guidelines emphasising the provision of nutritional supplementation to only those who are malnourished or at a high risk of malnourishment, an emphasis on the use of first line dietary advice (Food First), and regular patient reviews Defining malnutritionMalnutrition is both a “cause and a consequence of ill-health”.1 The term malnutrition can apply to various states – under-nutrition, over-nutrition or deficiencies of specific nutrients. This article will concentrate on under-nutrition, and the term malnutrition when used will refer to this state. More specifically, malnutrition in this context refers to a deficiency in protein and energy, with or without micronutrient deficiencies. Such deficiencies are associated with a decline in body functioning and clinical outcome. The consequences of malnutrition are physiological, biochemical and psychological. They include reduced immunity, delayed wound healing and decreased muscle strength, which in turn have detrimental effects on recovery and rehabilitation. The psycho-social impact of malnutrition is also significant with changes in mood, attitude, self esteem and reduced socialisation.1,2,3 Prevalence of under-nutrition
Causes of malnutritionThe “anorexia of ageing”6,7 Appetite and food intake often decline with ageing. Older people tend to be consistently less hungry than younger people, eat smaller meals, have fewer snacks between meals and also eat more slowly.8 Between age 20 and 80 years, there is on average, a decrease in energy intake of approximately 30%. When this decline in energy intake is more than the decrease in energy use that is also normal with ageing, then there is loss of weight.8 Most people lose weight as they age, but the amount lost is variable and those that are already lean, also lose weight. The problem with this weight loss is that it is not only unwanted adipose tissue that is lost but lean skeletal muscle.9 The loss of lean tissue is associated with reductions in muscle function, bone mass and cognitive function, anaemia, dysfunction of the immune system, slow wound healing and recovery from surgery, and consequentially an increase in both morbidity and mortality.8,9 Although lean muscle can be regained in younger people this is often not the case for elderly people. This means that being underweight becomes more of a health problem in older age, than being overweight. Increasing age has several effects on gastrointestinal function. Secretion of gastric acid, intrinsic factor and pepsin is decreased, which then reduces the absorption of vitamin B6, B12, folate, iron and calcium. Other gastrointestinal problems such as gastritis and gastrointestinal cancers can reduce nutritional status.10 A hypermetabolic state where there is increased resting energy use can be caused by acute respiratory or urinary infections, sepsis, cirrhosis of the liver, hyperthyroidism and the hyperactive state found in some people with dementia or Parkinson’s disease.10 Chronic obstructive pulmonary disease (COPD) can cause anorexia and physical problems related to shortness of breath (see here). In addition to the “anorexia of ageing”, there are physical, social, cultural, environmental and financial reasons for an inadequate diet.1,8 Impaired intakePoor appetite: illness, pain or nausea when eating, depression or anxiety, social isolation or living alone, bereavement or other significant life event, food aversion, resistance to change, lack of understanding linking diet and health, beliefs regarding dietary restrictions, alcoholism, reduced sense of taste or smell. Inability to eat: confusion, diminished consciousness, dementia, weakness or arthritis in the arms or hands, dysphagia, vomiting, COPD, painful mouth conditions, poor oral hygiene or dentition, restrictions imposed by surgery or investigations, lack of help while eating for those in hospitals and rest homes. Lack of food: poverty, poor quality diet (home, hospital or rest home), problems with shopping and cooking, ethnic preferences not catered for, particularly in hospitals and rest homes. Medicines: medicines can alter nutritional status in numerous ways, e.g. anorexia, decreased or altered taste, dry mouth, confusion, gastrointestinal disturbance including nausea, vomiting, diarrhoea, constipation, dyspepsia. Incorrect use of medicines may also cause problems, e.g. hypermetabolism with thyroxine and theophylline.10 Impaired digestion and/or absorption: Medical and surgical problems affecting stomach, intestine, pancreas and liver, cancer, infection, alcoholism Altered requirements: Increased or changed metabolic demands related to illness, surgery, organ dysfunction or treatment. Excess nutrient losses: Vomiting, diarrhoea, fistulae, stomas, losses from nasogastric tube and other drains. Illness related Malnutrition: Some disease states also increase the risk of malnutrition. For example chronic respiratory, gastrointestinal, liver and kidney diseases, cancer, HIV, AIDS, stroke and surgery.1 Surgery: The metabolic changes caused by surgery, the increased demands required for successful healing, sepsis and the stress of the surgical procedure itself, all increase energy needs.11 To supply this energy, protein stored as muscle is broken down and amino acids released. A septic state will increase this muscle breakdown further. Nutritional requirements must meet these increased needs. Furthermore, patients may already be malnourished due to the illness that led to their surgery. Once discharged, there will be ongoing higher nutritional needs during the recovery phase, although muscle lost may never be regained. Oral nutritional supplements may be useful during the recovery period, particularly if there are modifications to dietary intake as a consequence of the surgery, e.g. texture modification, low residue diet. Cancer: People with cancer are often malnourished. Physical and metabolic changes can be compounded by social and psychological problems.12 Treatment adverse effects such as taste changes, nausea or swallowing difficulties also result in a reduced food and nutrient intake. Cancer may result in cachexic syndrome which is a state of complex metabolic changes associated with anorexia, progressive weight loss and depletion of reserves of adipose tissue and skeletal muscle. Weight loss adversely affects treatment tolerance and survival outcomes. Nutritional advice tailored on an individual basis should be given at an early stage to help prevent nutritional deficiencies.13 Loss of appetite, pain, nausea and vomiting all contribute to poor oral intake. Prednisone may be used to stimulate appetite, but its effect tends to be short lived.14 Oral nutritional supplements can be beneficial when a normal balanced diet cannot be tolerated. These supplements help prevent malnutrition but eventually cannot halt the cachexic state associated with many end-stage cancers. Chronic Kidney Disease (CKD)15 Nutritional requirements for people with CKD vary widely. In general, they require a diet that promotes adequate nutrition, minimises biochemical abnormalities and delays the progression of CKD. In later stages of CKD appetite is often poor and there is a high risk of malnutrition. Guidance should be given to ensure the protein intake meets the recommended daily intake for the patients’ age and gender and adequate energy is consumed. Micronutrients such as potassium and phosphorous should only be restricted if blood levels are elevated. The aim of treatment is to prevent malnutrition. People requiring haemodialysis have some differing needs – they require 1.2 – 1.4 g/kg/day of protein due to losses in the dialysate. Some people may require adjustment of micronutrient intake, but this is dependent on the individual’s clinical and biochemical profile. There are specialised renal nutritional supplements available on the Pharmaceutical Schedule. These are indicated for patients requiring volume and potassium restrictions. For many patients, standard oral nutritional supplements will be suitable in the first instance. How do we detect under-nutrition?The onset of nutritional problems is often gradual and therefore hard to detect. However, features found in the history and examination may help identify those at risk. People can present with a variety of problems that may be vague or non-specific. Patients may report reduced appetite and energy and have altered taste sensation and changes to their normal bowel habit.1 Clinical features that may suggest under nourishment include low body weight, fragile skin, wasted muscles, recurrent infections and impaired wound healing.1 A malnourished state is defined as any of the following:1
Screening for malnutrition riskIn many cases clinical judgment is sufficient to diagnose under-nutrition. However, not everyone who is malnourished is thin. Objective classification of a patient’s risk of malnutrition assists clinical decision making. A validated and reliable nutrition screening tool is the first step in identifying at risk patients. NICE clinical practice recommendations for nutrition screening1Screening should take place for:
Screening should also be considered at other opportunities, e.g. health checks, influenza injections, and repeated regularly for people in recognised risk groups. Nutrition screening is defined as a quick and simple evaluation that detects the risk of malnutrition and guides implementation of a clear action plan.1,16 The NICE guidelines recommend the Malnutrition Universal Screening Tool (MUST) which aggregates scores for BMI, unintentional weight loss (over three to six months) and an acute illness or lack of adequate food for more than five days.1 Malnutrition Universal Screening Tool (MUST)Malnutrition Universal Screening Tool (MUST)MUST was originally designed for residential and community settings, however, it has now been validated in the acute setting, allowing screening to occur across the continuum of care. It takes on average three to five minutes to complete and includes clear treatment plans depending on the level of risk identified (Figure 1). The full MUST toolkit includes tables that allow scoring of BMI and % weight loss without having to calculate the individual indices. These can be printed for clinical use. There is also a MUST calculator available to further speed up the screening process. The complete MUST toolkit is available for download from: An on-line calculator for MUST is available from: Figure 1: The MUST screening tool (from www.bapen.org.uk)
Re-assess subjects identified at risk as they move through care settings Laboratory testingLaboratory testing is not useful for diagnosing malnutrition, however, some tests may be required to detect specific deficiencies such as iron, folate and vitamin B12.1,10 Albumin has been suggested in the past as a marker of nutritional status but it is now regarded as unhelpful due to the fact that it can be altered by clinical conditions such as dehydration and inflammation.17 Re-feeding SyndromeRe-feeding syndrome occurs when nutrition support is re-introduced too quickly after a period of significantly reduced intake or starvation. The subsequent change from fat to carbohydrate metabolism causes alterations in electrolyte levels, such as hypophosphataemia, hypokalaemia and hypomagnesaemia. Thiamine levels may also be reduced.18 NICE recommends that people who have eaten little or nothing for five or more days have nutrition support introduced slowly, at a rate of 50% of requirements. Patients at high risk of re-feeding syndrome should be managed by a team who has expert knowledge of nutritional requirements and care.1 Patients at high risk of re-feeding syndrome1 One or more of the following:
Two or more of the following:
Nutrition support strategiesNutrition support is not limited to providing supplements in the form of oral nutritional supplements (ready-made liquids or powdered sip feeds) or enteral feeding. The first step should always be to maximise an individual’s nutritional intake from regular food and drink, often termed “Food First”. The Food First approach includes increasing the frequency of eating, maximising the nutrient and energy density of food and drink and fortifying food with the addition of fats and sugars. Strategies to optimise adequate oral nutrition are summarised in Table 1. Table 1: Ways to optimise oral nutrition in elderly people10,19
In some situations a Food First approach can be sufficient to correct malnutrition outcomes (see “Practical food suggestions”).5 For patients who are at very high risk of malnutrition or for whom first-line dietary measures are not sufficient, oral nutritional supplements should be considered in combination with the Food First approach.1,16 Practical food suggestions for people who are malnourishedHealthy eating guidelines promote low fat and low sugar food choices. Patients who are malnourished or losing weight unintentionally, however, must rely on fat and sugar as concentrated sources of calories. The benefit of energy dense foods in these circumstances should be explained to patients and carers to assist compliance. Ideally fats should be heart healthy (oils, margarines, seeds and nuts) but with the priority being to ensure an energy dense intake. Calories from butter, cream, full fat milk and cheese can be utilised. General suggestions for a Food First approach may include:
Meal and snack suggestions
Other beneficial products available in supermarkets include Complan, Vitaplan and Up & Go. These products are not nutritionally complete and should not be used as a sole source of nutrition. They can, however, be used as part of the Food First approach as the overall emphasis for these patients should be eating foods high in calories and protein. Oral nutritional supplementsOral nutritional supplements are nutritionally complete liquid supplements that contain a mix of macro and micronutrients. These products are available from pharmacies in:
Evidence that oral nutritional supplements improve health outcomes is limited. A systematic (Cochrane) review of 62 trials, updated in 2009, concluded that there was evidence of small consistent weight gain following the use of oral nutritional supplements and that for undernourished patients mortality is possibly reduced.3 In addition, there was greater evidence of a reduction in complications compared to previous reviews but the reviewers noted that the data was limited and of poor quality. A further review of dietary advice for illness related malnutrition in adults could not clearly define whether dietary advice or supplements provided better outcomes.20 The reviewers concluded that nutritional intervention (oral nutritional supplement plus other dietary measures) was more effective than no intervention on enhancing short term weight gain but whether survival or morbidity are improved remains uncertain. All reviews agree that oral nutritional supplements are useful means of increasing protein, energy and micronutrient intake when used appropriately and as part of a combination of nutrition support strategies.1,3,16 The success of oral nutritional supplements can be limited by a lack of compliance often due to low palatability, adverse effects, e.g. nausea and diarrhoea, and by cost.16 Some studies have shown that there can be a decrease in the consumption of normal foods when oral nutritional supplements are given,16,21 whereas other studies found no effect on appetite.22 Wastage of up to 35% of these products is also reported.23 Best results are seen when people are offered a variety of different flavours and consistencies and also when the temperature at which the products are consumed is varied.16 Oral nutritional supplements should be given between meals, not at meal times and there is some evidence of improved adherence if administered in small regular doses similar to a medicine.5 They are not usually intended as a food replacement but as a supplement. As part of clinical monitoring, prescribers should check that patients are using oral nutritional supplements appropriately, as a top up to their food intake rather than a replacement. Ensure patients are clear about the role of oral nutritional supplements in their overall nutritional care. After trying Food First, oral nutritional supplements should be considered where a patient has been identified at medium to high risk of malnutrition, ideally in combination with Food First. The prescription should be based on the gap between the patient’s estimated requirements and how much they are managing orally. The need for continuation of an oral nutritional supplement should be monitored regularly and adjusted as malnutrition risk reduces.1,5 Considering prescription of oral nutritional supplementsVocationally registered medical practitioners are now able to make initial applications for Special Food Special Authorities. It is intended that dietitians will also be able to make applications in the near future. The eligibility criteria for Special Authorities give clear guidance on who should be considered for oral nutritional supplements. The reduced time span of initial applications encourages regular monitoring and evaluation of continuation of oral nutritional supplements. The evaluation pathway is summarised in Figure 2. Figure 2: The evaluation pathway summary * Monitoring and evaluation considerations may include:
Suitable oral nutritional supplements for patients who have been identified at risk of malnutritionPoints for consideration:
Table 2: Nutritional composition of the ready-made and powdered drinks when mixed with water and milk
Note: these instructions may vary from the mixing instructions on some of these products Changing from ready-made liquids to a powderWhen considering whether it is suitable for a patient to change from a ready-made liquid sip feed to a powdered sip feed the main considerations are; the purpose for which the patient needs the sip feed, the nutrient density of the sip feed, hidden costs and convenience. Powdered sip feeds are not suitable for tube feeding. The ready-made sip feeds are fully subsidised where prescriptions are endorsed with “Bolus fed through a feeding tube”. It is possible to also use fully subsidised tube feeding formula. Refer the patient to a dietitian for full review and recommendations. Nutritional contentThe ready-made liquid sip feeds, e.g. Ensure Plus and Fortisip, are 1.5 kcal/mL with 12 – 13g of protein per serve. In comparison, the powdered sip feeds (Ensure Powder and Sustagen Hospital Formula) when mixed with water according to the instructions provide 1.0 kcal/mL with 8.5 g and 13.8 g protein/serve respectively. By making a direct switch to standard dilution powdered drinks the nutrient density is reduced. This can be overcome if the powder is mixed with milk, the patient drinks a larger volume, or the powder is concentrated (refer to the mixing instructions in Table 2). Tips for patients using powdered products
Once mixed, it can be drunk straight away. Any leftover mixture can be covered and placed in the fridge for up to 24 hours. After 24 hours it should be thrown away. Powdered products can be mixed with other food:
Make a fruit smoothie by blending the made up mixture with:
Enteral feedingIn its broadest sense enteral nutrition refers to any feeding method that uses the gastrointestinal tract. More commonly, however, the term enteral feeding refers to methods of providing food via a tube directly into the gastrointestinal system. The tube can be inserted through the nose to the stomach (nasogastric) or to the small intestine (nasoduodenal or nasojejeunal). Alternatively a feeding tube can be placed via the abdominal wall directly into the stomach (gastrostomy). Percutaenous Endoscopic Gastrostomy (or PEGs) refers to gastrostomy tubes that are placed using endoscopy.16 Enteral (tube) feeding should be considered for people who cannot eat and drink safely, such as with dysphagia following a stroke. It can also be used when people cannot maintain an adequate diet from normal food and fluids or from oral supplements. If tube feeding is likely to be required for more than four weeks, then insertion of a PEG/gastrostomy tube may be required.16 The main benefit of gastrostomy tube over a nasogastric tube is patient comfort. It is also less likely to be displaced and can be hidden under clothes.1 However, a PEG is invasive and the risk of aspiration remains with both nasogastric and PEG feeding.24 NICE recommends that tube feeding in the community is delivered by health professionals trained in nutrition support using a coordinated multidisciplinary team approach.1 The team should include dietitians, district nursing, GPs and community pharmacists. Additional allied health staff should be involved as needed, e.g. speech and language therapists, occupational therapists. Monitoring of tolerance and oral intake by the team will provide guidance of when enteral feeding should be stopped.1 The use of tube feeding in people who are chronically unwell is controversial, especially when used for people with dementia. The debate focuses on the selection of which people will benefit from this form of nutritional supplementation.25 Both oral supplements and tube feeding can improve the nutritional state of people with dementia. European Society Parenteral and Enteral Nutrition (ESPEN) guidelines recommend that its use be considered in early and moderate dementia, however, not in terminal dementia. The decision regarding the use of tube feeding must always be made on an individual basis with input from relatives, caregivers, GP, therapists and if required, legal representation.16 Considerations for the use of long-term tube feeding may include:16
Caution! Medicines and enteral feeds should not be mixed. Temporarily stop the tube feed flush with water, administer individual medicines, flushing the tube before and after each dose. Resume feeding. Parenteral nutritionParenteral nutrition is a method of providing nutrition directly into the venous system, usually via a central line and so avoiding the digestive system. It is referred to as total parenteral nutrition and in general is used in a hospital setting. Its use in the community is mainly reserved for people with severe Crohn’s disease, those with vascular damage to the bowel and some people with cancer. Home parenteral nutrition is expensive and requires careful patient selection and training and should be managed by a healthcare professionals trained in parenteral nutrition. AcknowledgementThank you to Professor Tim Wilkinson, Associate Dean, Christchurch School of Medicine and Health Sciences, University of Otago and Dr Sandy McLeod, Medical Director, Nurse Maude Hospice, Christchurch, for expert guidance in developing the original article which appeared in BPJ 15 (Aug, 2008). References
Which of the following best describes the effect of aging on the immune system?Which of the following best describes the effect of aging on the immune system? Antibiotics are often ineffective in treating infections in older people who have deficient immune systems.
Which term refers the clouding of the eye lenses that impairs vision and can lead to blindness?Cataracts are cloudy areas in part or all of the lens of the eye. In people without cataracts, the lens is crystal clear and allows light to pass through and focus on the retina. Cataracts prevent light from easily passing through the lens, and this causes loss of vision.
Which substance has the biggest role in the development of atherosclerosis?Atherosclerosis is the underlying cause of heart attack and stroke. Early observations that cholesterol is a key component of arterial plaques gave rise to the cholesterol hypothesis for the pathogenesis of atherosclerosis.
Which of the following is a telling symptom of kwashiorkor?an enlarged tummy ("pot belly") regular infections, or more serious or long-lasting infections. red, inflamed patches of skin that darken and peel or split open. dry, brittle hair that falls out easily and may lose its colour.
|