Malnutrition in hospitals - Geoffrey Axiak's Nutrition Pages

MALNUTRITIO

N IN HOSPITAL

MALNUTRITIO

N IN HOSPITAL

By Geoffrey Axiak

By Geoffrey Axiak

B.Sc.(N

ursing), S.R.N., Dip. R. & C. Hypnotherapy (T.O.R.C.H.),

B.Sc.(N

ursing), S.R.N., Dip. R. & C. Hypnotherapy (T.O.R.C.H.),

P.G.Dip. (N

utrition &

Dietetics)

P.G.Dip. (N

utrition &

Dietetics)

Clinical Nutrition Nurse

Clinical Nutrition Nurse

St. Luke

St. Luke’’ s Hospital

s Hospital

Defining malnutrition

Defining malnutrition --11

�Malnutritionis the condition that develops when

the body does not get the right am

ount of the

vitam

ins, m

inerals and other nutrients it needs to

maintain healthy tissues and organ function (Fyke,

2003).

�It occurs in people who are either undernourished

(e.g. P.E.M

.) or over-nourished

(e.g. obesity).

Defining malnutrition

Defining malnutrition --22

�The World Health Organisation (W.H.O.) defines

malnutritionas “the cellular im

balance between

the supply of nutrients and energy and the body’s

dem

and for them

to ensure growth, maintenance

and specific functions”.

�Malnutrition can encompass a wide range of

deficiencies

(e.g. protein-energy) and excesses

(e.g. obesity). However, one area –under-

nutrition–has emerged as a priority area (Reuben et

al.,1995).

Stress, e.g.

infection/

trauma

PEM

(Kwashiorkor)

Absolute deficit

in protein but energy intake

relatively adequate

(esp. Carbohydrate)

Increased insulin:

cortisol ratio

Maintenance of:

Skeletal

muscle

Subcutaneous fat

Little wasting: patient

looks deceptively

well fed

Shortage of am

ino

acids for albumin

synthesis. M

ore

importantly, albumin seeps

out of blood into

surrounding tissues

Albumin levels fall quickly

Oedem

a: m

oon-faced

PEM

(Marasmus)

Absolute deficit

in protein and

energy

Decreased insulin:

cortisol ratio

Mobilisationof:

Skeletal

muscle

Subcutaneous

fat

Wasting

Albumin levels

fall slowly

Pathogenesis of malnutrition

Pathogenesis of malnutrition

Causes of malnutrition

Causes of malnutrition

��Poverty

Poverty

��Inadequate food intake

Inadequate food intake

��Chronic disease / illness

Chronic disease / illness

��Old age

Old age

��Decreased absorption

Decreased absorption

��Abnorm

al m

etabolism

Abnorm

al m

etabolism

��Hospitalisation

Hospitalisation

Malnutrition in hospital

Malnutrition in hospital --11

�On the 5thDecem

ber 2001, the BBC issued front-

page new

s: Hospital Patients –‘M

alnourished on

Arrival’. “An incidence of one patient in every

five admitted to hospital in the UK was found to

be malnourished, and this [they say] may be an

underestimate of the true scale of the problem”

(BBC, 2000).

Wednesday, 5 December, 2001, 12:06 GMT



�Malnutritionin hospital is a well-documented and

significant problem and contributes to increased

recovery tim

es, length of stays, cost to the health

services and patient mortality and m

orbidity.

�Surveysshow a very high incidence of

malnutrition among adults in surgical wards in the

UK (Hill et al.,1977, cited in Lennard-Jones, 1992),

Australia (Zader

& Trusw

ell, 1987, cited in Lennard-

Jones, 1992)and America (Bistrianet al.,1974, cited in

Lennard-Jones, 1992).



�P.E.M

.in hospitalised patients is usually due to:

–Difficulties with chew

ing, sw

allowing, digesting food,

pain, nausea and lack of appetite.

–Nutrient loss can be accelerated by bleeding, diarrhoea,

malabsorption disorders and other factors.

–Fever,

infection,

surgery,

trauma, burns

and some

medications and benign or malignant tumours increase

the am

ount of nutrients needed by patients.

–Severe sepsis, inflam

matory disease and surgery switch

on inflam

matory mediators whose job is to mobilise

muscle tissue to provide am

ino acids for an effective

acute-phase response.

A Case In Point: M

alta

A Case In Point: M

alta

��In M

alta a

In M

alta a 40%

40%

incidence of malnutrition was

incidence of malnutrition was

identified in patients undergoing renal dialysis on

identified in patients undergoing renal dialysis on

a regular basis (HD or CAPD)

a regular basis (HD or CAPD) (A

xiak, 2003).

(Axiak, 2003).

None

None

were referred for nutritional assessm

ent and help.

were referred for nutritional assessm

ent and help.

��Only

Only 22-- 3%

3%

of ward patients are referred to the

of ward patients are referred to the

Clinical Nutrition Services (St. Luke

Clinical Nutrition Services (St. Luke’’ s Hospital)

s Hospital)

for treatm

ent of malnutrition

for treatm

ent of malnutrition (Clinical Nutrition

(Clinical Nutrition

Services Statistics, M

alta, 2003).

Services Statistics, M

alta, 2003).

Nutritional status that

gets more precarious

Increased length of stay and

decreased access to services

Increased m

orbidity and

increased m

ajor complications

Prolongation / aggravation

of malnutrition

Increased

mortality

Increase in

care

prolongation

Return to compromised

home food supply

Unplanned

readmission

The vicious circle of malnutrition

The vicious circle of malnutrition

in hospital

in hospital

Under

Under-- recognition of

recognition of

malnutrition in hospitals


�Numerous research studies have documented the

inability of many health care providers to identify

nutritional deficit vulnerability and early and

advanced m

alnutrition status (Ennis et al.,2001).

This sets chronically ill patients on a carousel of

morbidity (Ward, 2001).

�Rollins (2002)mentions a frequency of 70%

of

malnutrition that is unrecognised in hospital

outpatients.

Reasons for under

Reasons for under-- recognition of

recognition of



�While healthcare staffregularly m

onitor patients

for adverse changes in respiratory function, fluid

and electrolyte balance, the effects of starvation or

semi-starvation often go unrecognised.

�Clinical nutritionis not taught to the present

generation of doctors, and it is still a cinderella

subject in undergraduate medical and nursing

schools (N.M

.E., 1983, cited in Lennard-Jones, 1992;

Judd, 1988, cited in Lennard-Jones, 1992; Plester, 1996).

Causes of malnutrition in the


elderly

elderly --11

��Restricted resources for purchasing and

Restricted resources for purchasing and

storing food

storing food

��Poor dental status

Poor dental status

��Social isolation

Social isolation

�Depression and bereavem

ent

�Stomach problems & indigestion,

malabsorption

�Pain / immobility



elderly

elderly --22

��Medications causing anorexia

Medications causing anorexia

��Sensory defects

Sensory defects

��Respiratory disease

Respiratory disease --causing

causing

hyperventilation &

increased energy

hyperventilation &

increased energy

requirem

ents

requirem

ents

�Carcinoma of the oesophagus, pharynx and

gut -may constitute m

echanical

obstructions to intake of food

�Dietary compliance problems

Pnem

onic

Pnem

onic for Treatable Causes

for Treatable Causes

of Malnutrition

of Malnutrition (Morley &

Silver, 1995)

(Morley &

Silver, 1995) ––11

[[ MEALS

MEALSON

ON W

HEELS

WHEELS]]

�Medication

�Emotional problems (depression)

�Anorexia

�Late-life paranoia

�Swallowing disorders

�Oral factors

�No m

oney

Pnem

onic

Pnem

onic for Treatable Causes

for Treatable Causes

of Malnutrition

of Malnutrition (Morley &

Silver, 1995)

(Morley &

Silver, 1995) ––22

[[ MEALS

MEALSON

ON W

HEELS

WHEELS]]

�Wandering &

other dem

entia-related

behaviour

�Hypertension, hyperthyroidism,

hypoadrenalism

�Enteric problems (m

alabsorption)

�Eating problems (inability to feed oneself)

�Low-salt, low-cholesterol

�Social problems (ethnic food preferences,

isolation)

Signs associated with


malnutrition

malnutrition --11

Body A

rea

Sig

ns Ass

ocia

ted W

ith M

aln

utr

itio

n

Hair

Lack of natural shine; dull, dry, sparse, straight, colour changes (flag

sign); easily plucked

Face

Dark skin over cheeks

and under eyes (m

alar and supraorbital

pigmentation), scaling of skin around nostrils (nasolabial seborrhea)

Oedem

atous face (moon face)

Colour loss (pallor)

Eyes

Pale conjunctivae

Bitot’s spots, conjuctival and corneal xerosis, soft cornea

Redness and fissuring of eyelid corners

Lip

s

Redness and swelling of mouth or lips, angular fissure and scars

Tongue

Red, raw and fissured, sw

ollen

Magenta colour

Pale, atrophic

Filiform

papillary atrophy



malnutrition

malnutrition --22

Tee

th

Carious or missing

Mottled enam

el (fluorosis)

Gum

s

Spongy, bleeding, may be receded

Gla

nds

Thyroid enlargem

ent

Parotid enlargem

ent

Skin

Follicular hyperkeratosis, dryness with flaking

Hyperpigmentation

Petechiae

Pellagrous dermatitis

Scrotal and vulval dermatisos

Nails

Spoon nails, brittle or ridged



malnutrition

malnutrition --33

Musc

ula

r and

skeletal sy

stem

s

Muscle wasting

Frontal and parietal bossing; epiphyseal sw

elling; soft, thin infant

skull bones, persistently open anterior fontanelle; knock-knees or

bow-legs

Beading of ribs

Intern

al sy

stem

s

Gastrointestinal

Nervous

Cardiac

Hepatomegaly

Mental confusion and irritability

Sensory loss, motor

weakness, loss of

position sense, loss of

vibration, loss of ankle and knee jerks, calf tenderness

Cardiac enlargem

ent, tachycardia

Diagnosing malnutrition

Diagnosing malnutrition

��Anthropometric measures

Anthropometric measures

––Weight, height, BMI, skinfold thickness, calf &

Weight, height, BMI, skinfold thickness, calf &

mid

mid-- arm

circumference, waist

arm circumference, waist-- toto-- hip ratio

hip ratio

��Dietary analysis

Dietary analysis

––Dietary history, recall m

ethods, food diary

Dietary history, recall m

ethods, food diary

��Laboratory studies

Laboratory studies

––Se. albumin, se. transferrin, retinol

Se. albumin, se. transferrin, retinol --binding

binding

protein, prealbumin, ? se. potassium

protein, prealbumin, ? se. potassium

BMI

Consequences of malnutrition

Consequences of malnutrition

��Reduced renal function

Reduced renal function

��Im

paired wound healing

Impaired wound healing

��Constipation, diarrhoea, pain

Constipation, diarrhoea, pain

��Respiratory failure

Respiratory failure

��Skeletal m

uscle atrophy

Skeletal m

uscle atrophy

��Increased length of stay

Increased length of stay

��Surgery stress, increased m

etabolic rate

Surgery stress, increased m

etabolic rate

��Reddish hair, atrophy of tongue papillae

Reddish hair, atrophy of tongue papillae

The spiral of events in

The spiral of events in

malnutrition

malnutrition

Precipitating cause of malnutrition

Weakness & m

isery

Norm

ally nourished

M A L N U T R I T I O N

Depression

Depressed organ function

Infection

Decompensatedorgan failure

A N O R E X I A

DEATH

Apathy

Reduced food intake

Treatment of malnutrition

Treatment of malnutrition

��Sip feeds / bars / yoghurt

Sip feeds / bars / yoghurt-- like cans

like cans

��Enteral feeding

Enteral feeding

––via N.G. / N.J. / P.E.G. / Gastrostomy tube

via N.G. / N.J. / P.E.G. / Gastrostomy tube

��Parenteral feeding

Parenteral feeding

––via central line

via central line

��Special parenteral feeding

Special parenteral feedinge.g. intradialytic TPN

e.g. intradialytic TPN

��advantages &

disadvantages exist!

advantages &

disadvantages exist!

Screening for malnutrition

Screening for malnutrition

�As Sakla

(2001)states “screening identifies at-risk

patients who require more thorough assessment,

which involves a

careful medical history and

physical exam

ination as well as anthropometric

and laboratory m

easurements”.

��Education programmes

Education programmes

help increase

help increase

understanding about choosing food.

understanding about choosing food.

��Governments should develop

Governments should develop policies

policies..

The Situation In M

alta

The Situation In M

alta

��No full

No full-- tim

e dieticians available at the moment.

time dieticians available at the moment.

��No screening service is available.

No screening service is available.

��Malnutrition is treated only in 2

Malnutrition is treated only in 2-- 3% of cases.

3% of cases.

��No teaching at Medical School about Clinical

No teaching at Medical School about Clinical

Nutrition.

Nutrition.

��Few

lectures in Nursing curricula but very little

Few

lectures in Nursing curricula but very little

about Healthy

about Healthy ‘‘Nutrition

Nutrition’’as such. Few

lectures

as such. Few

lectures

on Clinical Nutrition, i.e. artificial feeding (e.g.

on Clinical Nutrition, i.e. artificial feeding (e.g.

nasogastric

nasogastric, P.E.G., gastrostomy, T.P.N.).

, P.E.G., gastrostomy, T.P.N.).

��Alm

ost no research in this area.

Alm

ost no research in this area.

Conclusion

Conclusion

��Merck M

anual

Merck M

anual

(2003)

(2003) : :

––““The key to early detection is awareness that the

The key to early detection is awareness that the

persons in certain circumstances have a high risk of

persons in certain circumstances have a high risk of

malnutrition. Prevention of malnutrition, especially via

malnutrition. Prevention of malnutrition, especially via

regular screening is the answ

er, or rather, the best way

regular screening is the answ

er, or rather, the best way

to treat malnutrition

to treat malnutrition””..

Thank you!

Thank you!

Body Mass Index (BMI)

Body Mass Index (BMI)

Weight

Height2

<18.5 = underweight

18.5-25 = norm

al

25-30 = overweight

30-35 = obese I

>35 = obese II

Malnutrition in hospitals - Geoffrey Axiak's Nutrition Pages

Documents

Transcript of Malnutrition in hospitals - Geoffrey Axiak's Nutrition Pages