Nutritional Risks and Determinants in Older Adults

Question 1

malnutrition in older adults

Answer 1

often due to undernutrition in older adults (energy and/or nutrients), and can include obesity

Question 2

sarcopenia in older adults

Answer 2

age-related loss of muscle mass and strength

Question 3

cachexia in older adults

Answer 3

disease-related loss of muscle mass and strength; in the presence of fat mass loss
* underlying disease is the driver

Question 4

malnutrition in older adults across different settings

Answer 4

• most malnourished in rehabs and hospitals
• community dwellers are the least malnourished

Question 5

What are comprehensive assessments of nutritional status in older adults?

Answer 5

Used to diagnose malnutrition/undernutrition and develop and implement a treatment plan
* anthropometric
* clinical
* biomechanical
* dietary intake

Question 6

Anthropometric assessments

Answer 6

• body mass index (BMI) - not great though
• body composition (skin folds, BIA, DXA)
• circumference
• unintentional weight loss of more than 5% BW in 1 month, 7.5% BW in 3 months, 10% BW in 6 months

Question 7

clinical assessments

Answer 7

• nutrition focused physical assessment
• functional assessment
• cognitive and psychological function
• socioeconomic and health factors

Question 8

What to look at with nutrition focused physical assessment

Answer 8

• musculature
• body fat
• mucosa
• hair
• skin
• nails
• eyes

Question 9

What to look for with a functional assessment

Answer 9

• activities of daily living (ADL) - Activities needed to live life healthy and safe in a dignified way (bathing, washroom, feeding)
• instrumental activities of daily living (IADL) - Things that are great to be independant but are not life requirements (grocery shopping, laundry, managing finances)
• functional measures of muscle mass

Question 10

Dietary Assessment

Answer 10

• 24-hour recall
• Food records (3-7 days)
• Food frequency questionnaire
• Diet history

Need to consider cognitive decline, remembering 3-7 day food records can be burdensome

Question 11

Biochemical Assessment

Answer 11

• protein status assessment
• immune function assessment
• serum cholesterol
• vitamin and mineral biomarkers (interest in specific nutrient)
• Also blood samples, urine samples, biological tissue samples

Question 12

protein status assessments

Answer 12

Usually need to be paired with other measures
* albumin
* transferrin
* prealbumin (transthyretin)
* retinol-binding protein

Question 13

Immune function assessment

Answer 13

lymphocyte count - immune system is the most responsive organ to changes in nutrition status! T-cell is often used clinically
* C-reactive protein: if suspect infection or underlying inflammation

Question 14

Why might serum cholesterol by assessed?

Answer 14

hypocholesterolemia occur
late in the course of malnutrition

Question 15

What is the gold standard for nutritional assessment versus what is used?

Answer 15

Comprehensive assessment is the golden standard (anthropometrics, clinical, dietary and biochemical information) but is high resource intensive (expertise, time, costs), can’t be routine for all older adults so a screening tool is used instead

Question 16

How do screening tools differ from a comprehensive nutritional assessment?

Answer 16

Is a quick yes and no that can be done rapidly to identify those who may benefit from further evaluation
* standardized methods to identify individuals for follow-up (some tools also assess presence of malnutrition)
* based on factors that are known to be related to nutritional status
* tools need to be reliable and valid

Question 17

What are the common screening tools used?

Answer 17

• mini nutritional assessmnet (MNA) for older individuals
• Subjective global assessment (PGA) is used in the hospital

Question 18

Factors Included in Screening and Assessment Tools

Answer 18

• Anthropometrics
• diet intake
• factors that effect food intake
• clinical condition
• social factors

Question 19

anthropometrics included in the screening tool

Answer 19

• Change in weight (hallmark!!)
• BMI
• Arm or calf circumference

Question 20

dietary intake measures included in the screening tool

Answer 20

• Change in intake
• Intake/eating frequency
• Intake of certain foods
• Food avoidances
• Fluid intake
• Use of meal replacers
• supplements
• nutrition support

Question 21

factors that effect food intake included in the screening tool

Answer 21

• Chewing or swallowing problems
• Appetite
• feeling of fullness
• Ability to taste
• Ability to shop and/or cook
• Ability to feed self (TPN?)
• Financial resources

Question 22

clinical conditions included in the screening tool

Answer 22

• Presence of disease/illness
• GI symptoms
• Medication use (poly-use)
• Motor disability
• Cognitive function
• Psychological stress

Question 23

social factors included in the screening tool

Answer 23

Thinking beyond the individual
* Living situation
* Eating with others
* Social isolation (one of the biggest risk factors for malnutrition!!)
* Alcohol intake/smoking

Question 24

Sensitivity and Specificity of Screening and Assessment Tools

Answer 24

Important to balance
* Sensitivity = ability of test to correctly identify those with the disease / condition (malnutrition)
* Specificity = ability of test to correctly identify those who do not have the disease /condition (do not want to overdiagnos)

Question 25

Flow Diagram for Screening and Assessment

Answer 25

* Population to be tested does screeing test and is separated into negatives (free of condition) postitives (increased risk) * Positives go through diagnositic procedures and need to correctly capture the individuals with the present condition and intervene and identify those without the condition so as to not overdiagnos ## Footnote never occurs perfectly

Question 26

Advantages and disadvantages of MNA and SGA

Answer 26

Screeing and assessment tools **Advantages**: * Identify nutritional risk and diagnosis malnutrition * High sensitivity and specificity **Disadvantages**: * Requires health professional administration * more time to complete and higher costs

Question 27

Components of full MNA

Answer 27

evaluate the risk of malnutrition in older adults and permit early nutritional intervention when needed * professionally administered and relatively easy to administer and inexpensive * Has screening section (short form): 6 questions and if no red flags then done & full assessment: screening plus 12 other questions * based on score: normal nutritional status (high score), at risk of malnutrition, malnourished (low score) * Self-MNA: screening section completed by older adults, advised to consult health professional if score indicates at risk; further assessment

Question 28

sensitivity and specificity of MNA

Answer 28

High sensitivity (89-96%) and specificity (94-98%) to detect nutritional risk and diagnose malnutrition

Question 29

Components of SGA

Answer 29

Assess risk of nutritional complications in clinical population (not just for older adults) * individuals with medical conditions, hospitalized patients * professionally administered * based on assessment: well-nourished (A), mild- moderate undernutrition (B), severe undernutrition (C)

Question 30

sensitivity and specificity of SGA

Answer 30

high sensitivity (82%) and specificity (72%) * SGA diagnoses presence of undernutrition but does not detect nutritional risk * subjective assessment of professionals

Question 31

What are physical signs to look for with malnutrition?

Answer 31

Will look at specific areas of the body * eyes can see fat wasting * triceps wasting (skin without muscle) * look at ribs * wasted muscle on forearm * temple goes inward * depletion of muscle at shoulders * edema * washing of subclavia * Ulcers on legs

Question 32

Advantages and disadvantages of short screeing tools

Answer 32

* **Advantages**: Identify those at risk and need full assessment * **Disadvantages**: not diagnostic & equires health professional administration

Question 33

CNST

Answer 33

Canadian Nutrition Screening Tool (short screening tools) which does screening for nutritional risk in hospitals to identify patients who need SGA/nutrition consult * professionally administered * only two questions * sensitivity 67-73% and specificity 80-86%

Question 34

What are the 2 questions on the CNST?

Answer 34

1. Have you lost weight without trying? 2. Have you been eating less than usual?

Question 35

Advantages and disadvantages of self-admistered tools

Answer 35

**Advantages**: * Inexpensive, can screen large number of individuals, and can be utilized during regular check-ups * Targets community dwelling older adults * Raises awareness of nutrition risks **Disadvantages**: * Lower sensitivity and specificity, not diagnostic

Question 36

What is the DETERMINE checklist?

Answer 36

self-administered screening tool targeted to community-dwelling older adults * used only as a screening and educational tool * relatively inexpensive * low sensitivity ~49% and specificity ~64% (using a lower score (total 4 rather than 6) to indicate high nutritional risk improves sensitivity)

Question 37

What NSI?

Answer 37

Nutritional Screening Initiative which includes two levels of professionally administered assessment based on score, red flag if too high of points * **Level I Screen**: anthropometrics (height, weight, BMI); eating habits; living environment; functional status * **Level II Screen**: level I screen plus mid-arm circumference; triceps skinfolds; serum albumin, serum cholesterol; drug use information; clinical features; mental/cognitive status

Question 38

What is SCREEN-II?

Answer 38

Seniors in the Community Risk Evaluation for Eating and Nutrition that is self administered * self-assessment tool targeted to community- dwelling older adults * 14 questions about weight, eating habits, factors that affect intake * administrator calculates score; based on score: low risk, at risk, high risk * sensitivity ~84% and specificity ~60%

Question 39

What happens after screening?

Answer 39

older adults identified as at risk for malnutrition should receive a comprehensive nutrition assessment

Question 40

What are the goals of assessment?

Answer 40

* to confirm the presence of malnutrition and assess its severity * establish baseline data to evaluate the efficacy of the nutrition therapy provided

Question 41

Why do we care about Malnutrition?

Answer 41

**Higher Mortality** * 44% in malnourished patients vs 18% in well-nourished patients * 80% in malnourished CHF patients **Increases Length of Hospital Stay** * costs of obesity & overweight are ~1/2 the costs of malnutrition

Question 42

How do we Identify Older Adults at Risk of Malnutrition?

Answer 42

1. nutrition screening: all patients (can be done by patients) 2. nutrition assessment: detailed examination looking at whole person 3. nutrition intervention will depend on what you find

Question 43

Potential nutrition intervention strategies

Answer 43

* Alter diet prescription/diet order * Liberalize diet * Food fortification * Provide food/meal preferences * Recommend vitamin/mineral supplement * Oral Nutritional Supplements (ONS) * Enteral Nutrition * Parenteral Nutrition

Question 44

Goals of nutrition intervention

Answer 44

* Provide sufficient amounts of energy, protein, and micronutrients * Maintain or improve: Nutritional status & function, activity, and capacity for rehabilitation & quality of life * Reduce morbidity and mortality

Question 45

What factors might influence dietary intake?

Answer 45