Labs: Indicators for Nutritional Intervention

Labs: Indicators for Nutritional Intervention

Suzanne Neubauer, PhD, RD, CNSDFramingham State University

MA DHCC ConferenceSeptember 30, 2010

Overview

Disease States/ConditionsEvidence of malnutritionPressure ulcersDiabetesAnemia

Nutrition Care ProcessNutrition Diagnosis

Labs Intervention

3

What is the evidence to support a relationship between nutritional status and increasing age?

female gender cognitive decline loss of appetite swallowing

problems

low activity leveleating dependencyrecent hospitaliz-

ation and admission to healthcare communities

Grade I: Goodevidence or risk of malnutrition,

declining nutritional status and adverse health effects was associated with

http://www.adaevidencelibrary.com/conclusion.cfm?conclusion_statement_id=251257

What is the evidence to support that underweight or unintended weight loss is associated with increased mortality in adults over age 65?

Grade II Fair One study reported that mortality was 50% for

subjects with a BMI under 20 kg/m2

additional research suggests that the current BMI thresholds may not apply to the elderly

Two studies reported that weight loss was associated with a two- to 10-fold increased risk for death

One study reported that those who were severely underweight were four times more likely to have unintentional weight loss of 10 lbs in six months.

http://www.adaevidencelibrary.com/conclusion.cfm?conclusion_statement_id=251258

Unintended Weight Loss in Older Adults

What is the evidence to support the use of particular instruments for nutrition assessment of older adults with unintended weight loss?Grade I: Good

http://www.adaevidencelibrary.com/conclusion.cfm?conclusion_statement_id=251146

Instruments for Nutrition Screening

Most widely studied and validated instruments in the elderly are:Mini Nutritional Assessment Short Form

(SF)Nutrition Screening Initiative DETERMINE

Your Nutritional Health (DETERMINE)

http://www.adaevidencelibrary.com/conclusion.cfm?conclusion_statement_id=251146

Simplicity Is simple to perform and easily interpreted

Acceptability Is acceptable to the older adult

AccuracyProvides an acceptable measurement of the condition being investigated

CostHas cost equal with the benefits, or benefits exceed cost

Precision and

reliability

Obtains results by different investigators that are consistent when repeated with the same elder

SensitivityProvides a positive finding when the elder has the condition being investigated

SpecificityOffers negative findings when the screened elder does not have the condition under investigation

Holmes, S. (2000) “Nutritional screening and older adults.” Nursing Standard 15(2):42-44.

Seven Criteria for Establishing the Value of Screening

Procedures

Mini-Nutritional Assessment Short Form (MNA-SF) developed to identify older adults at

nutritional risk Provide for intervention planning short, accurate, six-question version of the

full MNA, (18 questions) takes about three minutes to give to an older

adult first step of a two-step screening process

second step involves a dietitian confirming “at-risk” status by giving the full MNA or another assessment.

Mini Nutritional Assessment (Full Form)

http://www.mna-elderly.com/mna_forms.html

Anthony PS, Nutr Clin Pract. 2008;23:373-382.

MM

Anthony PS, Nutr Clin Pract. 2008;23:373-382.

Nestle Mini Nutritional AssessmentMNA Cont’d

Mini-Nutritional Assessment-Short Form (SF)

Overviewhttp://www.mna-elderly.com/default.html

Form MNA video 12-14 points: Normal nutritional status 8-11 points: At risk of malnutrition 0-7 points: Malnourished

DETERMINE Your Nutritional Health

Designed byAmerican Academy of Family

Physicians in partnership withAmerican Dietetic Association andNational Council on the Aging

as part of the Nutrition Screening Initiative (NSI).

http://www.aafp.org/afp/980301ap/edits.html, Accessed 9/26/10)

DETERMINE Your Nutritional Health

Used by professionals working with elders to assess their risk for poor nutritional

status or malnutritionto measure an individual’s change in

level of nutritional risk over time.a decrease in the score indicates a

corresponding decrease in the elder’s nutritional risk.

Nutrition Checklist is based on the warning signs (DETERMINE)

http://www.aafp.org/afp/980301ap/edits.html, Accessed 9/26/10)

Disease

Any disease, illness or chronic condition that causes you to change the way you eat, or makes it hard for you to eat, puts your nutritional health at risk. Four out of five adults have chronic diseases that are affected by diet. Confusion or memory loss that keeps getting worse is estimated to affect one out of five or more of older adults. This can make it hard to remember what, when or if you've eaten. Feeling sad or depressed, which happens to about one in eight older adults, can cause big changes in appetite, digestion, energy level, weight and well-being.

http://www.aafp.org/afp/980301ap/edits.html, Accessed 9/26/10)

Eating Poorly Eating too little and eating too much both

lead to poor health. Eating the same foods day after day or not eating fruit, vegetables and milk products daily will also cause poor nutritional health. One in five adults skips meals daily. Only 13 percent of adults eat the minimum amount of fruits and vegetables needed. One in four older adults drinks too much alcohol. Many health problems become worse if you drink more than one or two alcoholic beverages per day.

http://www.aafp.org/afp/980301ap/edits.html, Accessed 9/26/10)

Tooth Loss/Mouth Pain

A healthy mouth, teeth and gums are needed to eat. Missing, loose or rotten teeth or dentures which don't fit well or cause mouth sores make it hard to eat.

http://www.aafp.org/afp/980301ap/edits.html, Accessed 9/26/10)

Economic Hardship

As many as 40 percent of older Americans have incomes of less than $6,000 per year. Having less--or choosing to spend less--than $25 to $30 per week for food makes it very hard to get the foods you need to stay healthy.

http://www.aafp.org/afp/980301ap/edits.html, Accessed 9/26/10)

Reduced Social Contact

One-third of all older people live alone. Being with people daily has a positive effect on morale, well-being and eating.

http://www.aafp.org/afp/980301ap/edits.html, Accessed 9/26/10)

Multiple Medicines Many older Americans must take medicines for

health problems. Almost one half of older Americans take multiple medicines daily. Growing old may change the way we respond to drugs. The more medicines you take, the greater the chance for side effects such as increased or decreased appetite, change in taste, constipation, weakness, drowsiness, diarrhea, nausea and others. Vitamins or minerals when taken in large doses act like drugs and can cause harm. Alert your doctor to everything you take.

http://www.aafp.org/afp/980301ap/edits.html, Accessed 9/26/10)

Involuntary Weight Loss/Gain

Losing or gaining a lot of weight when you are not trying to do so is an important warning sign that must not be ignored. Being overweight or underweight also increases your chance of poor health.

http://www.aafp.org/afp/980301ap/edits.html, Accessed 9/26/10)

Needs Assistance in Self-Care

Although most older people are able to eat, one of every five has trouble walking, shopping, buying and cooking food, especially as they get older.

http://www.aafp.org/afp/980301ap/edits.html, Accessed 9/26/10)

Elder Years Above Age 80

Most older people lead full and productive lives. But as age increases, risk of frailty and health problems increase. Checking you nutritional health regularly makes good sense.

http://www.aafp.org/afp/980301ap/edits.html, Accessed 9/26/10)

DETERMINE Your Nutritional Health

http://www.aafp.org/afp/980301ap/edits.html

Total your nutritional score. 0-2 Good! Recheck your nutritional score

in six months.3-5 You are at moderate nutritional risk.

Recheck your nutritional score in three months.

6 or more You are at high nutritional risk..

Assessment of Food, Fluid and Nutrient Intake

Recommendation: Strong/Imperative

RD and/or DTR should assess and evaluate food, fluid and nutrient intake in older adults with unintended weight loss

Research reports decreased intake of energy and nutrients in older adults who are acutely/chronically ill and/or underweight and those with cognitive impairment and dysphagia

http://www.adaevidencelibrary.com/template.cfm?template=guide_summary&key=2715

What is the evidence to support particular methodologies for the assessment of dietary intake in older adults with unintended weight loss?

Grade II: Fair Two studies support multiple days of assessment of

dietary intake Three studies reported that quantitative methods are

necessary to provide estimations of energy intake. How do we best assess dietary intake in the

institutional setting?

http://www.adaevidencelibrary.com/conclusion.cfm?conclusion_statement_id=251173

Malnutrition

When biochemical indicators are not available, is MNA enough?

31

What about Protein Levels?

Mueller states negative acute phase proteins are indicators of severity of illness which may predict malnutritionAlbumin, prealbumin, transferrin, RBP,

fibronectin C-reactive protein: most sensitive

indicator of inflammation

32

Acute-Phase Proteins Positive:

synthesis by ~ 25%

Orosomucoid α1 Acid glycoprotein

α1 Antitrypsin Haptoglobin Fibrinogen C-reactive protein

Negative: synthesis by ~ 25%

Albumin Prealbumin Transferrin Retinol binding

protein Fibronectin

Jensen GL, JPEN 2006;30:453-463

CRP

Rises until the catabolic phase of the stress response has subsided

Falls rapidly as anabolism begins If low serum protein levels are accompanied

by high CRP, inflammation mostly caused the depression

Normal CRP values vary but generally, there is no CRP detectable in the blood.

CRP: Risk for CVD

You are at low risk of developing cardiovascular disease if your hs-CRP level is lower than 1.0mg/L

You are at average risk of developing cardiovascular disease if your levels are between 1.0 and 3.0 mg/L

You are at high risk for cardiovascular disease if your hs-CRP level is higher than 3.0 mg/L

Prealbumin

Synthesized in the liver Half-life of ~ 2 days Higher sensitivity to changes in protein-

energy intake compared to other visceral proteins

In at-risk patients with low prealbumin levels, an increase of < 4.0 mg/dL/wk suggested inadequate nutrient intake

Chavez M. Is protein to Blame? Med Nutr Matters.2010;29:20-24.

Chavez M. Is protein to Blame? Med Nutr Matters.2010;29:20-24.

Chavez M. Is protein to Blame? Med Nutr Matters.2010;29:20-24.

Stechmiller AK, Cowan L, Logan KM. Nutrition support for wound healing. Supp. Line. 2009;31(4):2-8.

Tempest M, Siesennop E, Howard K, Hartoin K. Nutrition, physical assessment, and wound healing. Supp. Line. 2010;32(3):22-28.

Stechmiller AK, Cowan L, Logan KM. Nutrition support for wound healing. Supp. Line. 2009;31(4):2-8.

Zinc supplementation offers no benefit if the patient is not deficientZinc supplementation may interfere with copper absorption

Stechmiller AK, Cowan L, Logan KM. Nutrition support for wound healing. Supp. Line. 2009:31(4):2-8.

Hydration

Adequate fluid is essentialhydrate the wound siteaid in oxygen perfusiontransport materials to and from the

wound site Assessed through BUN, BUN/creatinine

ratio, Na, serum osmolality and urine specific

gravity in combination with above

Other Labs

Hypocholesterolemia< 160 g/dLWith poor appetite and weight loss

suggests at nutritional risk TLC C-reactive protein

Pressure Ulcer Case

93 yo female with recent left hip fracture Ht: 5’6” Wgt: 108 BMI 17 79% IBW po intake @ 50-75% of meals per nursing

Skips breakfastEats food which family brings

PMH: stage II pressure ulcer; dementia, CHF, HTN, osteoporosis, anemia, GERD

Meds: Megace, Protonix, Lopressor, 300 mg ferrous sulfate, digoxin, colace

Labs

Prealbumin: 13.7 mg/dL (16-40)RBC 3.79 (4.3-5.8)Hgb 11.8 g/dL (13-17)Hct 35.6 % (40-51)MCV 94 (80-100)MCH 31pg (27-33)BG 103 mg/dL (65-99)

PES Documentation

Problem…related to (RT)…

Etiology…as evidenced by (AEB)…

Signs or symptoms

Nutrition Care Process & PES

Nutrition Nutrition Nutrition Nutrition

Assessment Diagnosis Intervention Monitoring/ Evaluation

Problem Etiology Sign/Symptoms