The role of nutrition and nutritional supplements in vulnerable elderly patients

What is malnutrition

a state of nutrition in which a deficiency or excess of energy, protein and other nutrients causing adverse effects on tissue/body form and fucntion

Malnutriotion symptoms

• Weight loss

• Low BMI

• Reduced food intake

• Disease burden

• reduced metabolic regulation

cachexia

loss of skeletal muscle mass with or without loss of fat mass

non-reversible by conventional nutritional support

Cachexia symptoms

• weight loss/ low BMI

• decreased muscle strength

• abnormal biochem

• fatigue

• anorexia

Sarcopenia

reduction in skeletal muscle mass and function

part of aging process

consider muscle mass, muscle strength, physical performance

Sarcopenia symptoms

loss of mobility

reduced muscle function 

reduced physical performance 

Frailty

Increased vulnerability for developing increased dependency and or mortality when exposed to a stressor

PINCH ME

P ain IN fection C onstipation H ydration M edication E nvironmental

Risk factors for malnutrition

• old age > 65years

• care home/ nursing home

• complex health needs e.g. Learning difficulties or mental health disorders

• Chronic conditions e.g. diabetes, kidney disease, chronic lung disease

• dementia, cancer

• drugs, alcohol

What are some causes of malnutrition

What are some physiological consequences of malnutrition

• Frailty

• reduced fat and muscle

• poor wound healing

• reduced mobility, fatigue

• increased risk of infection

Weak cough

Poor absorption of nutrients

More side effects from medicines

What are some physiological consequences of malnutrition

Low mood / depression

Confusion

Appetite further reduced

What are some outcomes of malnutrition

More falls and pressure ulcers

More hospital admissions

More GP visits

Require more prescriptions

Longer length of stay

Reduced quality of life

Increased mortality

What guidelines can we use to identify malnutrtion

NICE guidelines

CQC 

MUST: Calculate BMI, % weight loss, acute disease affect score, overall risk of malnutrition, management guidelines

How do we measure disease related malnutrition

BMI less than 18.5 kg/m2

Unintentional weight loss >10% in the last 3-6 months

or

BMI less than 20 and unintentional weight loss of 5% in the last 3-6 months

eating little in the past and upcoming 5 days

poor absorptive capacity

How can we treat malnutrition

1. manage affecting factors

2. set treatment aims

3. food based nutrient dense diet

4. oral nutritional supplements

5. review + monitor

What factors can affect food intake

• difficulty swallowing

• unable to use cutlery

• constipation/ constipating medicines

• Nausea and vomiting

• do they struggle to buy/cook food

What kind of targets can be made

• avoid further weight loss

• achieve BMI 18.5 or 20

• wound healing 

• regaining lost weight

What should make up a nutrient dense fortified diet

Balance of protein, energy, fibre, electrolytes, vitamins, minerals

• Milkshakes

• high protein/high energy snacks

• fortified foods, avocado, cheese, nut, butter, seeds

• simple advice e.g. add nut butter to porridge, add cheese to soup, add milk powder to puddings

What multivitamins can be advicsed

Vitamin D 10 micrograms 400 iU

reduces mortality, complications, improves weight and function

what are some clinical considerations that make nutritional supplements inapporpriate

Dysphagia: cannot have thick fluids

renal impairment: affects protein and electrolyte 

pressure area; affects protein and micronutrient 

fluid restriction 

vegan, allergies, intolerances

What are some practical considerations that may be inappropriate

physical ability to make up milkshakes/powdered supplements

impact on compliance

What is the ACDB criteria for oral nutritional supplements

Short bowel syndrome

Dysphagia

Intractable malabsorption

Pre-operative preparation of undernourished patients

Inflammatory bowel disease

Total gastrectomy

Bowel fistulae

Disease related malnutrition (chronic/acute) – can be evidenced by MUST

MUST HAVE 2 OR MORE HIGH RISK FACTORS

ONS

prescribe 2 first line oral nutritional supplements

trial 2 weeks

consider flavours, acceptability

commonly milkshakes, juice, pudding, savoury

shots/powders/jellies/gels not balanced macro/micornutrients

How do we review and monitor patients

• record weight 

• Is there ACBS indication

• What is their MUST score

• food advice?

• aims of treatment

• supplements?

• cost effectiveness

• prescribed dose

• trialled supplement