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					Recognising under-nutrition in elderly patients
Nutritional status is often a neglected aspect in the assessment and
management of elderly patients. It is well recognised that under-nutrition makes
illness more difficult to treat and prolongs recovery. In this article, Drs Rajkumar
Parikh and Sarah Moore detail the scale and the causes of nutritional failure, and
examine some methods that can help the multidisciplinary team ‘spot those at
risk.’ Special nutritional challenges apply, for instance, in stroke care and
dementia patients.

Poor nutrition is associated with increased morbidity and mortality1,2. However,
equally important for the geriatrician and general practitioner is the frailty and
loss of function that is associated with inadequate nutrition. Recognising
nutritional problems is important not only in the acute hospital and care home
setting, but also in rehabilitation and discharge planning.

Malnutrition in the elderly is not new, but the ‘nutritional plight’ of elderly patients
has received more attention over recent years. This is partly due to demographic
change and the increasing numbers of poorly nourished people with multiple
pathologies1.Additionally, reports have shown that we don’t do very well. In 1997
‘Hungry in Hospital’ highlighted the failure of the NHS to meet the nutritional
needs of older patients. This failure is economically costly. The King’s Fund, in
1992, estimated savings of £226 million pounds could be made per annum in the
UK by adopting a proactive approach toward feeding undernourished patients.
The majority of the savings were made through reducing hospital stay and
complications3,4. This article will mainly focus on under-nutrition in hospital and
care home patients. Screening tools to detect under-nourished patients will also
be described.

Definitions
Malnutrition is an umbrella term which includes:
    Under-nutrition – inadequate food intake and/or the presence of
        metabolically active disease
    Over-nutrition – excessive intake
    Imbalance – disproportionate intake (e.g. excessive alcohol)1, 4.

Other terms encountered in nutrition research include:-
    Sarcopenia – the age-related loss of skeletal muscle mass. The
       relationship between sarcopenia and functional impairment is still to be
       fully established
    Protein-energy malnutrition (PEM) – defined by clinical signs, including
       weight loss, and biochemical evidence of inadequate intake such as an
       albumin of less than 3.5g/dl5, 6
    Anthropometric measurements – these include height, weight, skinifold
       thickness and circumferential measurements of various parts of the body.
       These reflect nutritional status and can be used to estimate the ercentage
       of body fat. These parameters are most useful as serial measures and are
       not particularly sensitive to acute changes.

Defining, and researching, under-nutrition in the elderly poses problems. For
example:
    There is no consensus on how best to define under-nutrition. Thus,
       comparing studies is often difficult. Consent to participate is a particular
       issue in this field – often those most at risk of malnutrition are those who
       cannot consent to enter a trial
   
       Many ‘normal’ nutritional parameters derive from work in younger adults. It
       is difficult to know whether the variations from these seen in older people
       represent under-nutrition, or are simply normal with ageing. In America
       and Europe, new age specific reference tables are becoming available 1, 2
    Many studies use Body Mass Index (BMI), but this has limitations.
       Cumulative height loss from age 30 to 70 years averages about 3cm for
       men and 5cm for women. Thus, age-associated loss of height artifactually
       increases BMI. Loss of lean body mass with age is accompanied by an
       increase in adipose tissue. Thus, the ability of BMI to partition the body
       into fat and fat free mass is lost2. In acute illness, despite an elevated BMI,
       patients can still have PEM.


Prevalence of under-nutrition

Under nutrition is very common. When defined as PEM, 30–65 per cent of
hospitalised elderly patients are under-nourished1. This is not surprising as 40
per cent of patients on admission are nutritionally compromised7. The National
Diet and Nutrition Survey of people aged 65 years or over found that in
residential care, a sixth of residents were malnourished (with a BMI less than 20)
compared with three per cent of men and six per cent of women of a similar age
living in the community8. In Scotland, an audit showed the prevalence of
malnutrition in ‘long term care elderly’ in the NHS and non-NHS sectors was 29
per cent4.

Causes of poor nutrition

Ageing does not lead to malabsorption, or malnutrition, with the exception of an
increased frequency of atrophic gastritis. Under-nutrition is a consequence of
social, psychological and physical factors such as:
     Loss of appetite
     Chewing problems
     Dysphagia
     Problems preparing food
     Immobility
     Dementia
     Depression
      Social isolation
      Blunted thirst and hunger regulation1,2,9.

Appetite is lost for a variety of reasons. Our sense of taste and smell deteriorate
with age, and diseases such as heart failure, dementia and malignancy can
reduce appetite1, 2. Loneliness, after the death of a partner, may also profoundly
impact on appetite and motivation to eat.

Other conditions have a profound functional impact. The patient with a
hemiplegia, or advanced Parkinson’s disease, may be physically unable to
prepare food. Stroke patients often have problems self-feeding and swallowing10.
Having fewer than 20 teeth, or wearing dentures, is also linked to difficulty
chewing and thus difficulty eating11.

In addition, unattractive monotonous food is often found in hospitals or care
homes. Forty per cent of food placed in front of elderly hospital patients is wasted
– equating to consumption of less than 70 per cent of energy and protein
requirements7. Insufficient nursing staff, rigid meal-times, and lack of snacks,
contributes to the lack of useful food4. Interruptions, including ward rounds,
means food may be cold when served3. Therefore, it is not surprising a fifth of
patients receive less than half of their energy needs whilst in hospital1, 3.

A further factor is polypharmacy. Loss of appetite, taste disturbance, nausea or
changes in mental function are associated with drug therapy1. Antibiotic
associated diarrhoea is sometimes associated with decreased food intake as a
coping strategy to reduce stool frequency. Increased energy is required in acute
illness, and energy input needs ‘stepping-up’ to meet demands. In chronic
obstructive pulmonary disease, and some malignancies, hyper-metabolism is
associated with anorexia1.

Assessing nutritional status

Health professionals recognise only a third of under-nourished patients.
Responsibility for nutrition is shared between medicine, nursing and dietetics 3, 12,
but as it is everyone’s job, no one may actually do it. Active intervention with oral
or naso-gastric feeds can prevent weight loss and decrease mortality by 30 per
cent, but whom do you target?

Nutrition screening tools can start the assessment process4. There are several
available, with each having strengths and weaknesses. Some, for example the
Mini Nutritional Assessment, rely heavily on anthropometrics, laboratory data and
dietary recall13. However, they are time consuming and thus impractical for a
ward or care home setting.

Easier and quicker instruments are available. Jordan et al described how the
Nursing Nutritional Screening Tool (NNST) was introduced into a district general
hospital3. The NNST focused attention on nutrition as an issue, but the study
failed to show improved outcomes. Partly, this was due to design flaws – patients
who were very ill or confused could not consent and were excluded.

Interestingly, organisational factors, including insufficient staff to help patients
eat, were identified as reasons for failure. Thus, the introduction of a screening
tool is the start, rather than the end
of change.

The Derby Nutrition Score (DNS) was developed in 1992 for use in adult
patients. The DNS was designed to be simple and quick to use. There are seven
domains:
1. Body weight for height
2. Mobility/ capability
3. Symptoms (gastrointestinal)
4. Skin integrity
5. Appetite/ intake
6. Psychological state
7. Age.

Each domain has a list of options each with a score contributing to the total. For
those with a score of over 10 out of a possible 28, a food chart and care pathway
(which may result in dietician referral) is commenced. The authors described its
implementation at Derby City Hospital and said that the brevity of the score,
combined with the fact it was ‘built in’ to the admission procedure, meant that 96
per cent of patients were screened and that the profile of nutrition elevated12.

Special circumstances

Specific conditions make patients especially vulnerable, for example stroke and
dementia.

Stroke
Stroke is associated with a range of problems that influence dietary intake. At
admission, 16–31 per cent of patients with a stroke are malnourished, as are
about half admitted to rehabilitation units. Malnutrition also correlates with death
and dependency. A Swedish study showed that 80 per cent of stroke patients in
a nursing home needed help to eat. This is combined with dysphagia (in a
quarter of patients), depression and poor appetite. This interaction of factors can
be difficult to modify10,14. The eating difficulties seen include functional problems
such as:
    Limited arm movement and ability to feed
    Poor sitting position – decreased ability to manipulate plated food
    Impaired lip closure and chewing
    Dysphagia
    Sensory inattention.
They also include psychological problems such as:
    Anxiety and shame due to coughing and drooling
    Fear of choking
    Depression10.

Reassurance, help with feeding, and mouth care are often all that is needed.
Modifying food consistency or using alternative methods, such as tube feeding,
can overcome under-nutrition in patients with dysphagia. The introduction of
evidence-based guidelines to aid multidisciplinary nutritional assessment in acute
stroke patients has been successful in London14.

Dementia
Similarly, a complex interaction of problems exists in dementia patients. Alois
Alzheimer described progressive weight loss in his first patient, and recent
longitudinal studies have also shown this. A Spanish study showed 16.5 per cent
of a group of institutionalised patients with moderate Alzheimer’s disease (AD)
had a BMI less than 21 (their criteria for under-nutrition)15. Under-nutrition is
encountered in all forms of dementia.

Causes include15, 16 inadequate intake due to:
   Swallowing problems
   Apparent food refusal
   Inability to feed – loss of motor planning
   Spitting and removing food from the mouth
   Distress during feeding.

They also include increased body requirements due to increased energy
consumption through agitation. The medial temporal cortex atrophy is also a
factor as this part of the brain plays a pivotal role in eating behaviour. The degree
of atrophy correlates with weight loss in AD.

Dealing with the above, especially behaviour problems, is challenging. A small
study in Derbyshire showed that multidisciplinary working benefited sufferers.
Nutrition and behaviour screening tools were used to identify those at risk and to
target interventions. To back this up there was a considerable background
change – for example the study described how the speech therapists and
caterers collaborated to introduce a series of different consistency meals.
Additionally, mealtimes stopped being the only time food was available. Snacks
were provided, and staff became less concerned with a ‘healthy diet’ and
accepted that any food was better than none. As motor skills declined with
disease progression, finger food was offered to get around the difficulties of using
cutlery16.
Improving nutrition in hospital and care facilities

Apart from recognising who is at risk, it is important to correct organisational
factors that stop people eating and drinking well. One way to do
this is to deconstruct each stage of the ‘feeding process’ into its component parts
to see where problems lie17. As stated, monotonous poorly prepared food, lack of
snacks and interrupted meals are common problems. In most cases simple
remedies can be found to improve the menu and promote good nutrition 4, 8.
Providing advice to patients about healthy eating is effective. Personalising it,
and limiting the number of educational messages presented at one time, makes
the advice memorable18, 19.

Conclusion

Under-nutrition commonly occurs in the elderly and is the result of a complex
interaction of factors – from depression to dysphagia. Recognising those at risk is
the first step in combating the considerable morbidity, mortality and financial
costs associated with this problem. Nutritional assessment is the responsibility of
all members of the multidisciplinary team, and simple screening tools are
available. Conditions such as stroke or dementia place patients at high risk of
under-nutrition. Changing the way food is prepared, or served, can make a
significant difference in improving consumption

Dr Rajkumar James Parikh is a Specialist Registrar in Geriatric Medicine at
Kettering General Hospital and Dr Sarah Moore is a Senior House Officer in
Integrated Medicine at Leicester General Hospital

Links

Return to Nutrition

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References

   1. Pirlich M, Lochs H. Nutrition in the elderly. Best Practice and Research Clinical
      Gastroenterology 2001; 15(6): 869–84

   2. Bates CJ, Benton HK, Biesalski HB, et al. Nutrition and aging: a consensus statement.
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   3. Jordan S, Snow D, Hayes C, Williams, A. Introducing a nutrition screening tool: an
      exploratory study in a district general hospital. Journal of Advanced Nursing 2003; 44(1):
      12–23

   4. National Nursing, Midwifery and Health Visiting Advisory Committee. Promoting Nutrition
      for Older Adult In-Patients in NHS Hospitals in Scotland. 2002; Scottish Executive.
      Available free at: www.scotland.gov.uk/library5/health/pnoap-00.asp (date last accessed:
      27/05/05)
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6. Jensen GL, McGee M, Binkley J. Nutrition in the elderly. Gastroenterology Clinics of
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7. Allison SP, Rawlings J, Field J, et al. Nutrition in the elderly hospital patient, Nottingham
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8. Copeman J. Promoting nutrition in older people in nursing and residential homes. British
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9. Beate Krinke U. The Role of Nutrition in Healthy Aging. Minnesota Medicine 2002; 85(9):
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10. Kumlien S, Axelsson K. Stroke patients in nursing homes: eating, feeding, nutrition and
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11. Budtz-Jorgensen E, Chung JP, Rapin CH. Nutrition and oral health. Best Practice and
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13. Vellas B, Lauque S, Andrieu S, et al. Nutrition assessment in the elderly. Current Opinion
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15. Gil Gregorio SP, Ramirez Diaz JM. Dementia and nutrition. Intervention study in
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16. Biernacki C, Barratt J. Improving the nutritional status of people with dementia. British
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17. Paquet C, St-Arnaud McKenzie D, Ferland G, Dube L. A blueprint-based case study
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18. Sahyoun NR, Pratt CA, Anderson A. Evaluation of Nutrition Education Interventions for
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19. Higgins MM, Barkley MC. Tailoring Nutrition Education Intervention Programs to Meet
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    79

				
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