A. Definitions: 1.

Malnutrition: Any disorder of nutritional status, including disorders resulting from a deficiency of nutrient intake, impaired nutrient metabolism, or over-nutrition. 2. Protein-energy under-nutrition: The presence of clinical (i.e., physical signs such as wasting, low body mass index [BMI]) and biochemical (i.e., albumin or other serum protein) evidence of insufficient intake. B. Etiology and/or Epidemiology. Older adults are at risk for under-nutrition due to dietary, economic, psychosocial, and physiological factors. 1. Dietary intake a. Little or no appetite. b. Problems with eating or swallowing. c. Eating inadequate servings of nutrients. d. Eating fewer than two meals a day. 2. Limited income may cause restriction in the number of meals eaten per day or dietary quality of meals eaten. 3. Isolation a. Older adults who live alone may lose desire to cook because of loneliness. b. Appetite of widows decreases. c. Difficulty cooking due to disabilities. d. Lack of access to transportation to buy food. 4. Chronic Illness a. Chronic conditions can affect intake. b. Disability can hinder ability to prepare or ingest food. c. Depression can cause decreased appetite. d. Poor oral health (e.g., cavities, gum disease, and missing teeth) and xerostomia, or dry mouth, impairs ability to lubricate, masticate, and swallow food. e. Antidepressants, antihypertensives, and bronchodilators can contribute to xerostomia (dry mouth). 5. Physiological changes a. Decrease in lean body mass and redistribution of fat around internal organs lead to decreased caloric requirements. b. Change in taste (from medications, nutrient deficiencies, or tastebud atrophy) can also alter nutritional status. Parameters of Assessment A. General: During routine nursing assessment, any alterations in general assessment parameters that influence intake, absorption, or digestion of nutrients should be further assessed to determine if an older adult is as nutritional risk. These parameters include the following:

1. Subjective assessment, including present history, assessment of symptoms, past medical and surgical history, and co-morbidities. 2. Social history. 3. Drug nutrient interactions: Drugs can modify the nutrient needs and metabolism of older people. Restrictive diets, malnutrition, changes in eating patterns, alcoholism, and chronic disease with longterm drug treatment are some of the risk factors in elderly that place them at risk for drug nutrient interactions. The U.S. Food and Drug Administration and National Institutes for Health have Internet resources for common drug nutrient interactions. 4. Functional limitations. 5. Objective assessment: physical examination with emphasis on oral exam (see Oral Health Care topic at www.ConsultGeriRN.org), loss of subcutaneous fat, muscle wasting, BMI12 and dysphagia. B. Dietary Intake: in-depth assessment of dietary intake during hospitalization may be documented with a 3-day calorie count (dietary intake analysis). C. Nutrition Risk Assessment Tool: The MNA should be administered to determine if an older hospitalized patient is either at risk for malnutrition or has malnutrition. The MNA determines risk based on food intake, mobility, BMI, history of weight loss, psychological stress, or acute disease and dementia or other psychological conditions. If the score is 11 points or less, the in-depth MNA assessment should be administered. D. Anthropometry 1. Obtain an accurate weight and height through direct measurement. Do not rely on patient recall. If patient cannot stand erect to measure height, then knee-height measurements should be taken to estimate height using special knee-height calipers. Height should never be estimated or recalled, due to shortening of the spine with advanced age; self-reported height may be off by as many as 2.4 cm. 1, 14 2. Weight history: A detailed weight history should be obtained along with current weight. Detailed history should include a history of weight loss, whether the weight loss was intentional or unintentional, and during what period. A loss of 10 pounds during a 6-month period, whether intentional or unintentional, is a critical indicator for further assessment. 3. Calculate BMI to determine if weight for height is within the normal range of 22 27. A BMI below 22 is a sign of under-nutrition. E. Visceral Proteins. Serum albumin, transferrin, and prealbumin are visceral proteins commonly used to assess and monitor nutritional status. 1 However, these proteins are negative acute-phase reactants; therefore, during a stress state, production is usually decreased. In an older hospitalized patient, albumin levels may be a better indicator of prognosis than nutritional status. Nursing Care Strategies A. Collaboration 1. Refer to dietitian if patient is at risk for or has under-nutrition. 2. Consult with pharmacist to review patient's medications for possible drug nutrient interactions. 3. Consult with a multidisciplinary team specializing in nutrition. 4. Consult with social worker, occupational therapist, and speech therapist as appropriate.

B. Alleviate Dry Mouth 1. Avoid caffeine; alcohol; tobacco; and dry, bulky, spicy, salty, or highly acidic foods. 2. If patient does not have dementia or swallowing difficulties, offer sugarless hard candy or chewing gum to stimulate saliva. 3. Keep lips moist with petroleum jelly. 4. Encourage frequent sips of water. C. Maintain adequate nutritional intake: Daily requirements for healthy older adults include 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. Caloric, carbohydrate, protein, and fat requirements may differ depending on degree of malnutrition and physiological stress. D. Improve oral intake 1. Mealtime rounds to determine how much food is consumed and whether assistance is needed. 2. Limit staff breaks to before or after patient mealtimes to ensure adequate staff are available to help with meals. 3. Encourage family members to visit at mealtimes. 4. Ask family to bring favorite foods from home when appropriate. 5. Ask about and honor patient food preferences. 6. Suggest small frequent meals with adequate nutrients to help patients regain or maintain weight. 7. Provide nutritious snacks. 8. Help patient with mouth care and placement of dentures before food is served. E. Provide conducive environment for meals 1. Remove bedpans, urinals, and emesis basin from room before mealtime. 2. Administer analgesics and antiemetics on a schedule that will diminish the likelihood of pain or nausea during mealtimes. 3.Serve meals to patients in a chair if they can get out of bed and remain seated. 4. Create a more relaxed atmosphere by sitting at the patient s eye level and making eye contact during feeding. 5. Order a late food tray or keep food warm if patients are not in their room during mealtime. 6. Do not interrupt patients for round and nonurgent procedures during mealtimes. F. Specialized nutritional support. 1. Start specialized nutritional support when a patient cannot, should not, or will not eat adequately and if the benefits of nutrition outweigh the associated risks. 2. Prior to initiation of specialized nutritional support, review the patient's advanced directives regarding the use of artificial nutrition and hydration.

G. Provide oral supplements- Supplements should not replace meals but rather be provided between meals but not within the hour preceding a meal and at bedtime. See National Collaborating Centre for Acute Care Clinical Guideline for algorithm for use of oral supplements. H. N.P.O. orders 1. Schedule older adults for test or procedures early in the day to decrease the length of time they are not allowed to eat and drink. 2. If testing late in the day is inevitable, ask physician whether the patient can have an early breakfast. 3. See American Society of Anesthesiologists practice guideline regarding recommended length of time patients should be kept N.P.O. for elective surgical procedures. Evaluation and Expected Outcomes A. Patient 1. Will experience improvement in indicators of nutritional status. 2. Will improve functional status and general well-being. B. Provider 1. Should ensure that care provides food and fluid of adequate quantity and quality in an environment conducive to eating, with appropriate support (e.g., modified eating aids) for people who can potentially chew and swallow but are unable to feed themselves. 2. Should continue to reassess patients who are malnourished or at risk for malnutrition. 3. Should monitor for refeeding syndrome. C. Institution 1. Will ensure that all health care professionals who are directly involved in patient care receive education and training on the importance of providing adequate nutrition. 15 D. QA/QI 1. Establish QA/QI measures surrounding nutritional management in aging patients. E. Educational 1. Provider education and training includes the following: a. nutritional needs and indications for nutrition support b. options for nutrition support (oral, enteral, and parenteral) c. ethical and legal concepts d. potential risks and benefits e. when and where to seek expert advice 2. Patient and/or caregiver education includes how to maintain or improve nutritional status, as well as how to administer, when appropriate, oral liquid supplements, enteral tube feeding, or parenteral nutrition.

Follow-up Monitoring A. Monitor for gradual increase in weight over time. 1. Weigh patient weekly to monitor trends in weight. 2. Daily weights are useful for monitoring fluid status. B. Monitor and assess for refeeding syndrome. 1. Carefully monitor and assess patients the first week of aggressive nutritional repletion. 2. Assess and correct the following electrolyte abnormalities: Hypophosphatemia, hypokalemia, hypomagnesemia, hyperglycemia, and hypoglycemia. 3. Assess fluid status with daily weights and strict intake and output. 4. Assess for congestive heart failure in patients with respiratory or cardiac difficulties. 5. Ensure caloric goals will be reached slowly during 3 to 4 days to avoid refeeding syndrome when repletion of nutritional status is warranted. 6. Be aware that refeeding syndrome is not exclusive to patients started on aggressive artificial nutrition but may also be found in elderly individuals with chronic co-morbid medical conditions and poor nutrient intake started with aggressive nutritional repletion via oral intake.