Elderly Patients and Malnutrition - Dissertation Example

?Elderly Patients and Malnutrition The overwhelming cases of malnutrition in the UK have led the government and health care professionals to dedicateserious efforts to alleviate the prevalence and risk especially among the elderly. Several proposals have been made in the current literature to stop malnutrition, particularly in the hospital setting. Nevertheless, the problem continues to worsen as the elderly population continues to increase in the 21st century. This paper provides an overview of current studies and approaches to fight malnutrition among elderly patients in hospitals. Several articles from scholarly journals from the 90s through the present were reviewed to assess which of the current nursing interventions mentioned are most effective for elderly patients. However, evidence-based research conducted in hospitals for the elderly is scant. Therefore, this paper relies on research on malnutrition management for the elderly in different settings in order to recommend the best nursing practices that can be applied in the hospital setting. Based on research findings, the current paper concludes with recommendations, hence contributing to the vast literature on the malnutrition issue and proposing government actions to fight malnutrition in the UK. Background of the study Malnutrition among the elderly has been noted since the early 90s (Stratton, Green and Elia 2003). In the report, the authors identified the prevalence and risks associated with malnutrition, targeting elderly patients in hospitals and home care settings. Moreover, the further increase of the elderly population in the next few years is bound to worsen the situation . In 2001, BBC reported that one in seven British elderly is malnourished . In 2007, the Nutrition Action Plan Delivery Board declared that 239 people died of malnutrition in British hospitals (Brimelow 2012). Conversely, Chapman (2010) claims that 50,000 people die of malnutrition every year. The alarming figures strongly suggest a serious concern on malnutrition, especially in the hospital setting. Hospital patients deserve expert and adequate care provided by health professionals. Nevertheless, as previous reports establish, hospital services are insufficient to meet the nutritional needs of ill patients. Given the present scenario, the government, along with health care professionals, faces a serious problem of alleviating the risks associated with malnutrition in the elderly population. Several proposals have been made in the past to address the current issue but the problem remains unresolved. It is therefore important to reassess current approaches to nursing practice and further expand research in the field of elderly care. To date, experts have identified proper screening and management as basic responses to the current problem. However, the diverse needs of elderly patients in the hospital setting demand comprehensive approaches and resources in the nursing practice. Additionally, the availability of resources is another question. For such reasons, nurses assigned in hospitals should have a wide background of the issue and the solutions to the problem. Basic information such as the causes, symptoms, and risks of malnutrition are therefore imperative and should be considered common knowledge in the nursing practice. To address the current issue, nurses in the hospital setting should, in the first place, be aware of the symptoms and causes of malnutrition. A working definition of malnutrition should lead every health care practitioner to be aware of the problems associated with malnutrition and to be sensitive to the symptoms at-risk patients have. According to Peters (1996), malnutrition is a ‘deficiency state which occurs when inadequate proteins, calories, or specific nutrients are ingested to meet an individual’s nutritional requirements’ (p.45). Malnutrition can cause varying adverse effects on body composition and function, especially among at-risk populations such as the ill and the elderly patients. The current literature identifies two types of malnutrition, namely, undernutrition and overnutrition. People suffering from undernutrition may have a body mass index (BMI) of less than 20.0 kg/m2. The case can be serious if a person has eaten very little or nothing at all for more than five days or if a person has lost five percent weight unintentionally over a three to six-month period (Maher and Eliadi, n.d.). Those suffering from overnutrition have food nutrient supply that does not match their bodies’ requirement. Thus, overnourished people may be in the habit of eating foods that contain excessive nutrients that the body does not need. Excessive nutrients not only put the body out of balance but they also cause adverse effects to threaten health such as hypertension, diabetes, cancer, etc. Such complications could later lead to death, thus making malnutrition a serious health issue. The prevalence of malnutrition among elderly patients in hospitals may be due primarily to tangible and intangible reasons. Tangible ones are those that are physically evident including lack of available resources including hospital resources, changes in physical ability of the patients, and dietary requirements whilst tangible reasons are mostly psychological aspects that relate to the behaviour and emotional stability of the patients. Psychological factors could include depression due to illness or length of hospital stay, anxiety, and lack of family support. In as much as tangible factors help health care professionals to detect the risks of malnutrition, intangible factors deter practitioners to save the patient from the problem. Therefore, nurses in hospitals should be vigilant not only to tangible factors but also and more to intangible or unobvious reasons in order to save at-risk patients. Lack of available resources including hospital resources may not be the worst problem leading to malnutrition among elderly patients, but its occurrence definitely raises the concern on the national level. Lack of resources for proper food, supplements, screening, monitoring and follow ups is on the hospital’s end. In this regard, such problems should be handled efficiently by health care professionals to ensure high quality services. Changes in physical ability of patients can also lead to malnutrition. These include loss of appetite due either to age or illness, lack of physical strength to feed oneself, being held nil by mouth or other conditions causing obstruction to the mouth, decreased metabolism, and side effects caused by drug intake. Changes in physical ability vary from one patient to another. These factors could trigger the worst malnutrition conditions because they are most difficult to manage. In particular, loss of appetite due to aging cannot be easily controlled. Elderly patients have a tendency to lose appetite because their fondness with food decreases as they age. This happens as the olfactory cavity decreases its functions with age (Boyce and Shone, 2006). Also, some parts of the digestive system do not function normally in elderly patients, causing constipation that could inhibit patients from eating (Nigam & Knight 2008). In addition, lack of physical strength to feed oneself is another factor impacting malnutrition. Confined elderly patients who suffer from Parkinson’s Disease, severe pain and vomiting, dysphagia, difficulty to swallow, and other conditions affecting the oral cavity may excessively reduce appetite leading to malnutrition. Decreased metabolism could also discourage patients to eat, along with side effects caused by drugs. Likewise, strict dietary requirements issued by dieticians or attending doctors could cause the patients not to eat much, hence suffer from malnutrition. Strict dietary requirements will lead patients to eat only those foods that are doctor-recommended. As such, patients are likely to dissuade eating. In addition, food in the hospital are limited and not based on the patients’ taste. In this regard, some interventions have been proposed to encourage patients to eat, thus avoid the risk of malnutrition. In addition, patients suffering from chronic illnesses face great risks of malnutrition due to psychological factors including depression caused by illness or length of hospital stay, anxiety, and lack of family support. Elderly patients are prone to depression because they have a tendency to feel they have a lesser chance of getting well. In adverse cases, elderly patients show signs of suicidal tendency by refusing to eat. In other cases, the length of hospital stay impacts the ability of patients to eat. Patients who stayed longer in hospitals had greater risks of malnutrition than patients who stayed only for a couple of days. Anxiety may also be seen as another problem along with lack of family support during feeding times. Elderly patients who refuse to eat sometimes do so because they feel neglected and withdrawn. Interventions relevant to these problems should then be known to clinical nurses in order to sufficiently help patients meet their dietary requirements. The nursing practice should be sensitive to the needs of patients and apply relevant interventions tailored to each need. Presentation of findings This chapter presents the current nursing practice relating to assessment and management of malnutrition cases in elderly care. The care for the elderly requires close monitoring and assessment because elderly patients are prone to complications and psychological problems conflicting health such as self-pity, depression, and anxiety. Also, some tend to deny sickness to avoid medications. To date, malnutrition in elderly people is greatly associated with increased morbidity and mortality among elderly people (Bienia et al. 1982; Flodin et al. 2000). Thus, current research strongly emphasises the need for prompt and comprehensive assessment at the time of admission in hospital settings and careful management of each cases should be taken seriously to avoid morbidity and mortality. Moreover, it should be noted that although there is plenty of evidence documenting effective practices in the management of malnutrition, nurses are bound to adhere to health care facility requirements in their local areas. Screening and monitoring Identifying patients at risk for malnutrition is the best way to prevent the problem (Brown, & Jones, 2009). Malnutrition and its adverse effects such as morbidity and mortality may be prevented with timely and proper screening and monitoring procedures. Several studies have been conducted to provide evidence of effective nursing practice relating to screening. A number of screening tools and checklists are available in the current literature. These include the Malnutrition Universal Screening Tool (MUST), the Geriatric Nutritional Risk Index by Bouillane et al. (2005), and the Nursing Nutritional Checklist (Thomas et al. 2000), which is a comprehensive checklist for screening malnutrition and care planning for elderly patients. The MUST is a screening tool developed by BAPEN, a charitable organisation based in UK. This screening tool involves five steps for screening elderly patients at risk for malnutrition. First, the tool requires determining the BMI of the patient. Second, the nurse obtains the weight loss score. Third, the nurse scores the acute disease effect score. Fourth, the nurse gets the sum of steps one, two and three to obtain the risk of malnutrition. Finally, the nurse develops a care plan in relation to the local policy or guidelines. The Geriatric Nutritional Risk Index (GNRI), a malnutrition screening developed by Bouillane and others is another tool that has been used in different studies such as Bouillane et al. (2005) and Cereda et al. (2006a, 2006b, and 2007). The GNRI makes use of the nutritional status of the patient and not just the BMI to accurately take into account the complications present in the elderly patients. The tool considers the albumin concentrations and the degree of weight loss of a patient. In Bouillane et al. (2005), the GNRI helped to establish whether patients were at risk of malnutrition and even other illnesses. In Cereda et al. (2006a; 2006b; 2007), total lymphocyte count was considered in patients’ GNRI to see complications related to poor nutrition. The Nursing Nutritional Checklist proposed by Thomas et al. likewise assesses the risks of patients to malnutrition. It includes a number of questions including weight loss in 30 days, BMI, list of laboratory results and symptoms of malnutrition, and other information that are required in assessing health status of patients. The checklist also includes suggested planning for patients at-risk, and recommendations for future actions done during follow ups. The screening tools available in the current literature commonly include parameters to identify at risk patients. These tools shall help every health care professional to address issues of malnutrition on the first day of hospitalisation and in the succeeding assessments for monitoring. However, according to Raja et al. (2008), despite the availability of these tools, nurses in some hospitals do not use them in the clinical practice, owing to the lack of knowledge of potential morbidity of patients and lack of system standards applied in hospitals. Interventions to malnutrition Identifying patients at risk is not enough to promote wellness. Thus, interventions to malnutrition are currently applied following screening of patients. Theory suggests that the earlier interventions are applied, the better chance there is of recuperation. As such, nurses should ensure application of relevant interventions at the onset of the problem or upon detection. In worse cases in which patients have been found ill, effectiveness of the intervention becomes crucial. Therefore, nurses should exercise care in deciding what interventions should be applied or recommended. The current literature presents numerous interventions to address problems of malnutrition in the elderly but not all of them are evidently effective. Alibhai, Greenwood, and Payette (2005) strongly recommend the use of non-pharmacologic interventions more than pharmacologic ones, noting the effectiveness of the former than the latter. Moreover, the authors consider the side effects of taking medicines to improve nutrition and weight gain, thus prefer non-pharmacologic interventions. According to them, both physical and psychological factors should be looked into to decide which interventions should be applied. Careful screening that includes consideration of demographic factors should be prioritised. Among interventions they recommend are minimising dietary restrictions, giving supplements, careful selection of food intake, ‘using community nutritional support services’ (172), among others. Pharmacologic therapy is likewise proposed in some studies (Brocker et al. 1994; Volicer et al. 1997; Yeh et al. 2000) especially in long-term hospitalisation of terminally ill and anorexic patients (Kardinal et al. 1990; Simons et al. 1996; Fietau et al. 1997). Other interventions that propose comprehensive efforts to address the problem of malnutrition include the red tray system (Bradley and Rees 2003), and educating patients and their families. In the next part of this paper, we review the best practices, giving importance to the recurrence of the interventions in evidence-based research. Minimising dietary restrictions Huffman (2002) and Bouras, Lange and Scolapio (2001) propose minimising dietary restrictions to promote eating and weight gain among elderly patients. In his paper, Huffman (2002) claim that medications to promote nutrition for the elderly may cause adverse body reactions such as vomiting, dysphagia, anorexia, and so on. As such, he proposes consideration of the patients’ interest to eat food, minimising obstructions to eating which may call for minimising dietary restrictions, and exploring efforts to prevent weight loss. These efforts, which exclude pharmacologic therapy, include identifying environmental and social factors that impede eating. Huffman (2002) provides a review of different studies. Remarkably, he notes that the incidence of unintentional weight loss among elderly patients in hospital setting is often due to terminal illness such as cancer. In home care, however, the risk is likely to occur among patients with psychological disorders. Unprecedentedly, the rate of malnutrition due to unidentified cause is found across all elderly patients, whether outpatients or inpatients. The xsame result is reflected in Thompson and Morris (1991), Lankisch, Gerzmann, Gerzmann and Lehnick (2001), Huerta and Viniegra (n.d.), and Levine (1991). This result reveals the fact that malnutrition may be attributed to other factors other than those mentioned above. If so, malnutrition among elderly patients may simply be due to poor eating habits. Poor eating habit in the hospital setting may be caused by a number of factors but clearly, one of which is the strict dietary requirement that patients have to follow and hospital dieticians have to serve. Nevertheless, if the main objective is to get elderly patients to eat, the best solution is to encourage them to eat by serving dishes that they would really eat. Promoting eating starts with providing foods that patients would love to eat. It is the nurse’s responsibility to take note of foods that their patients love in order to inform dieticians to prepare foods similar to or near in taste to the patient’s preference. It is also the nurse’s role to monitor the patient’s diet using risk assessment tools each time. In regard to encouraging patients to eat, risk assessment checklists should then include enquiries about the patient’s favourite food, eating habits or culture, and other factors that could contribute to healthy and happy eating. Bouras, Lange and Scolapio (2001) also propose minimising dietary restrictions. According to them, there are complex reasons for unintentional weight loss among older patients, including strict diets in hospitals. To reverse the problem, patients should be given enough attention, making sure to address factors that cause patients to be unwilling to eat. Giving supplements Poor eating habit is a common condition in the hospital setting. Payette, Boutier, Coulombe & Gray-Donald K provide evidence that prolonged hospital stay can cause patients to lose appetite and weight. To further address the problem, researchers have proposed giving supplements to boost the appetite, thus prevent malnutrition. Gazzoti et al. (2003) provide evidence of improved nutritional status of elderly patients during and after hospitalisation. Patients included in the study showed improved health conditions especially after hospital stay. However, the intervention did not show remarkable weight change. In Milne, Potter and Avenell (2002) & Johnson, East & Glassman (2000) elderly patients at risk of malnutrition improved their weight and eating habits after protein and energy supplementation. The authors recommend giving supplements to ill elderly patients despite showing no signs of weight loss. Pharmacologic therapy Reports on pharmacologic therapy provide evidence of its effectiveness especially among elderly patients (Gazzatti, 2003; Brocker et al. 1994; Yeh et al. 2000; Volicer et al. 1997) and anorexic and terminally ill patients (Kardinal et al. 1990; Simons et al. 1996; Fietau et al. 1997). Pharmacologic therapy pertains to the use of medicines such as orexigenic drugs to promote weight gain. Alibhai, Greenwood and Payette (2005) report studies providing evidence for the effectiveness of megestrol acetate to fight malnutrition. However, evidence of effectiveness for elderly patients is limited. In particular, Brocker et al. (1994) reports the effectiveness of megestrol acetate in independent-living patients whose appetite and energy to perform daily activities improved after the therapy for two months. Similarly, Karcic, Philpot and Morley (2002), Otttery, Walsh and Strawford (1998), and Castle et al. (1995) show evidence of effectiveness of megestrol acetate in patients suffering from anorexia or cachexia due to terminal illnesses such as AIDS and cancer. Another drug that has been noted to treat anorexia is dronabinol, a stimulant usually used for patients with cancer and AIDS. Jatoi et al. (2002), Berry and Mechoulam (2002), and Walsh, Nelson, and Mahmoud (2001) used dronabinol to improve weight of cancer patients, Beal, Olson and Levkovitz (1997; 1995) used for patients with AIDS, whilst Volicer, Stelly and Morris (1997) administered it to Alzheimer’s patients. Notably, the drug proved effectiveness in solving anorexia problems but its side effects including dizziness and somnolence suggest the need to prescribe the drug with caution especially for elderly patients. Family support The support of family members in the care of elderly patients is also seen as advantageous. Elderly patients in hospital settings may suffer a great deal of anxiety and stress due to the fear of not recovering, financial difficulty, lack of attention and support from family, and sometimes, loss of hope. When patients experience anxiety and depression, they are predisposed to malnutrition or unintentional weight loss. In many situations, the problem is psychological in nature. Reife (1995) proposes focusing attention on the psychological factors over physical factors affecting unintentional weight loss. He claims that psychological factors are more recurrent especially in elderly patients. As such, targeting psychological factors can promote faster recovery. The presence of family especially during feeding time is seen as an important factor to help improve weight gain and recovery from illness. Bouras, Lange and Scolapio (2001) support the finding that family assistance during mealtime greatly helps to improve health and weight of elderly patients. Furthermore, Brown and Jones (2009) propose employing dining assistance in hospitals to support and assist patients while eating. Exercise The benefits of exercise to improve appetite and overall health are also seen as a valuable of nutritional management. Performing exercise can help in proper absorption of nutrients as it helps the metabolism process. Dawe and Moore-Orr (1995) provide evidence supporting the need to implement exercise in elderly care. The age of the patients in the study ranged from 70 up. The single session mild exercises led the patients to have a better psychological disposition, thus increasing food intake. Physical exercise can help to alleviate stress and promote overall well-being. In Hebuterne, Bermon and Schneider (2001), exercise was seen as having anabolic effects to improve nutrition in elderly patients. The same positive result relating to the implementation of regular exercise to combat weight loss can be found in Ruuskanen and Ruoppila (1995) and Fiatarone, Marks and Ryan (1990). The said studies make exercise an important consideration in malnutrition management for the elderly. In De Jong, Chin, de Graaf and van Staveren (2000), exercise for elderly patients revealed a positive outcome after a 17-week intervention. The patients were reported to have better energy intake compared to their non-exercising counterparts. At the end of the study, the body mass and appetite improved continuously, and patients had a more positive outlook or regard for themselves. Red tray system The implementation of red trays in the UK was initiated by Bradley and Rees (2003). In their study, the authors introduced the use of red trays in Cardiff Royal Infirmary to address problems of malnutrition. Bradley and Rees (2003) claim that factors influencing poor nutrition in hospitals include problem with the way food is prepared and the system of supplying food. To address the identified problems, the authors proposed the implementation of red trays, which denote the extra need for nutritional support of patients issued with red trays. An assessment tool accompanied the red trays to monitor patients according to their weight, appetite, ability to eat, stress factors, and pressure sores or wounds (WAASP). Notably, authors found out that nurses failed to give attention to assessment tools in the past, thus none of the 30 patients who participated in the study were found to be at risk for malnutrition. Nevertheless, after the implementation of the red tray and WAASP, eleven patients were referred to dieticians. The implementation of the red tray system thus served as a reminder to nurses of their responsibility. However, its popularity in hospitals nowadays has not been accounted for because of the lack of further evidence in the current research besides that mentioned. Educating patients and their families One of the best ways to manage malnutrition is educating patients and their family or the people around them. Patients know their pains and thoughts; only they can fully know and feel what their bodies are going through. Therefore, they are the best persons to identify their wellness. The theory of nursing practice relates that patients should always be consulted for any clinical procedure, medication, or actions that they will be required to submit to. It is the patient’s right to be informed of the best approaches and alternatives to cure their illness. Considering this, educating patients is a foremost intervention that should be practised in any health care facility. Nevertheless, research and evidence relating to this practice is very limited. Educating patients and their families pertains to informing patients of the actions they need to take in order to fight malnutrition. The scope of educating patients and their families starts with informing patients of the probable risks of malnutrition. As such, educating patients and their families should start at the time of screening. Patients should be aware of the present conditions and actions they need to take in order to avoid morbidity. Educating family of the patients is also imperative to holistic nursing practice. Support coming from family is very important to facilitate recovery of ill elderly. In the case of elderly patients, the family can help to feed or assist the nurse during mealtimes. This effort has been proven to resolve eating problems of malnutrition caused by depression and anxiety (Reife 1995). However, nurses should also note that dependency during mealtimes is a negative behaviour leading to mortality (Siebens, Trupe, Siebens et al. 1986). The dependency of the patient could be a sign of depression and loss of hope, thus family members and nurses should note signs of dependency. To address the problem, they should encourage elderly patients to eat without assistance as long as the patient’s condition permits. The nurse plays an important role in educating patients and their family. Patients should be advised what to eat and what to avoid during mealtimes. Conclusion The current literature offers a number of screening tools and interventions to malnutrition. Among screening tools are the MUST, GNRI, and Nursing Nutritional Checklist. Commonly, these screening tools aim to guide nurses on proper screening of at-risk patients. They also ensure communication between the nurse and the patient, giving way for patients to express their needs and apprehensions relating to hospitalisation. Screening tools also serve as guide for making recommendations to doctors, dieticians, and other health care providers. Moreover, screening tools help to obtain the patient’s clinical history (allergies, psychological state, resistance to interventions, etc.), present symptoms, and possible complications of present illnesses. The screening tools found in the literature obviously vary in structure but they commonly aim at securing information about the patient. As such, nurses should use these tools to relevantly obtain required information. However, as Raja (2008) reported, many nurses in the current practice neglect the use of screening tools to identify patients at risk. The result of such is the failure to identify patients at risk, hence resulting in the overcoming number of patients, especially elderly patients, suffering from malnutrition or unintentional weight loss. Among different screening tools for malnutrition, the GNRI developed by Bradley and Rees (2003) is the most widely used because of its accuracy in generating results especially for ill patients. Unlike other screening tools that rely only on interviews and assessment of nurses, the GNRI considers albumin concentrations and other laboratory results to identify patients at risk. For this reason, GNRI serves as the most indicative and accurate tool for screening patients for malnutrition. Similar to screening tools, several interventions for the management of malnutrition in the elderly care have likewise been proposed in the literature, but the current statistics still report malnutrition as a national health problem. Among interventions mentioned in the current study are minimising dietary restrictions, giving supplements, pharmacologic therapy, family support, exercise, red tray system, and educating patients and family. Each of these interventions showed strengths and weaknesses in helping patients overcome malnutrition or unintentional weight loss. Among the proposed interventions, giving supplements and pharmacologic therapy are most popular in terms of the number of evidence sought. Likewise, the benefits of exercise to improve energy food intake are also well noted. Meanwhile, the current research has very little evidence relating to interventions that target psychological factors to malnutrition. Despite the popularity of pharmacologic therapy in research, this form of intervention is often employed to terminally ill patients such as those with cancer or AIDS. For this reason, pharmacologic therapy should be recommended with caution and nurses assigned to patients undergoing such intervention should be extra careful with the way they administer the drugs. The use of methods to resolve psychological factors effecting malnutrition is also seen as one of the best practices in the field of elderly care. Family support and minimising dietary restrictions hence allowing patients to eat what they want in order to correct malnutrition are the most friendly and cost-effective approaches. However, evidence supporting its effectiveness in fighting malnutrition is very limited. The interventions to malnutrition in the elderly population are plenty. Despite this, however, the problem of malnutrition in the elderly still raises a concern on the national level. Based on the literature, malnutrition is greatly associated with increased morbidity and mortality especially among elderly people (Bienia et al. 1982; Flodin et al. 2000). This fact should alarm every patient and health care professional, thus move them to exert the best efforts to fight malnutrition by alleviating the risks. Recommendations Approaches in the current nursing practice suggest a wide range of options for addressing the problem of health and nutrition. Basically, proper risk assessment and monitoring using applicable checklists should be seen as an imperative in the nursing practice. Subsequently, interventions should be properly applied depending on the varying needs of patients. As the current literature implies, proper screening using GNRI is the best practice to obtain the most accurate assessment. Furthermore, pharmacologic therapy and giving supplements are the most successful interventions based on the literature. However, it should be clear that pharmacologic therapy was often used in the past for preventing anorexia among terminally ill patients. Therefore, future research should examine the effectiveness of the intervention to elderly patients in general, including those who are not suffering from diseases. Nevertheless, extra care should be taken when administering drugs to patients, making sure of the absence of side effects. Exercise, educating patients and their families, and minimising dietary restrictions likewise emerge as other alternatives to pharmacologic therapy in fighting the problem of malnutrition in the field of elderly care. These alternatives offer the most natural and cost-effective options that many of elderly patients may find suitable. However, there is still lack of evidence illustrating the effectiveness of the said interventions. Therefore, future studies can explore the said topics and provide evidence to demonstrate their usefulness. References Alibhai, S Greenwood, C & Payette, H 2005, ‘An approach to the management of unintentional weight loss in elderly people’ CMAJ, vol. 172, no.6, pp. 773–780. Beal, JE Olson, R Lefkowitz, I et al.1995, ‘Dronabinol as a treatment for anorexia associated with weight loss in patients with AIDS’ Journal of Pain Symptom Management, vol.10, pp. 89–97. 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