Transcript Slide 1

Labs: Indicators for
Nutritional Intervention
Suzanne Neubauer, PhD, RD, CNSD
Framingham State University
MA DHCC Conference
September 30, 2010
Overview
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Disease States/Conditions
 Evidence of malnutrition
 Pressure ulcers
 Diabetes
 Anemia
Nutrition Care Process
 Nutrition Diagnosis
 Labs
 Intervention
What is the evidence to support a
relationship between nutritional
status and increasing age?
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Grade I: Good
 evidence or risk of malnutrition,
declining nutritional status and adverse
health effects was associated with
female gender
cognitive decline
loss of appetite
swallowing
problems
low activity level
 eating dependency
 recent hospitalization and admission
to healthcare
communities
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3
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?
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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
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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
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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
Seven Criteria for Establishing the
Value of Screening Procedures
Simplicity
Is simple to perform and easily interpreted
Acceptability Is acceptable to the older adult
Accuracy
Provides an acceptable measurement of the
condition being investigated
Cost
Has cost equal with the benefits, or benefits
exceed cost
Precision and Obtains results by different investigators that are
reliability
consistent when repeated with the same elder
Sensitivity
Provides a positive finding when the elder has
the condition being investigated
Specificity
Offers 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.
Mini-Nutritional Assessment
Short Form (MNA-SF)
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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)
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http://www.mnaelderly.com/mna_forms.html
Anthony PS, Nutr Clin Pract.
2008;23:373-382.
Nestle
Mini Nutritional Assessment
MNA Cont’d
MM
Anthony PS, Nutr
Clin Pract.
2008;23:373-382.
Mini-Nutritional
Assessment-Short Form (SF)
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Overview
 http://www.mnaelderly.com/default.html
Form
MNA video
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12-14 points: Normal nutritional status
8-11 points: At risk of malnutrition
0-7 points: Malnourished
DETERMINE
Your Nutritional Health
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Designed by
 American Academy of Family
Physicians in partnership with
 American Dietetic Association and
 National 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
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Used by professionals working with elders
 to assess their risk for poor nutritional
status or malnutrition
 to 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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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http://www.aafp.org/afp/980301ap/edits.ht
ml
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
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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?
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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
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When biochemical indicators are not
available, is MNA enough?
What about Protein
Levels?
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Mueller states negative acute phase
proteins are indicators of severity of
illness which may predict malnutrition
 Albumin, prealbumin, transferrin,
RBP, fibronectin
C-reactive protein: most sensitive
indicator of inflammation
31
Acute-Phase Proteins
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Positive: 
synthesis by ~
25%
Orosomucoid
α1 Acid glycoprotein
α1 Antitrypsin
Haptoglobin
Fibrinogen
C-reactive protein
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Negative: 
synthesis by ~
25%
Albumin
Prealbumin
Transferrin
Retinol binding
protein
Fibronectin
Jensen GL, JPEN 2006;30:453-463
32
CRP
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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
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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
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Synthesized in the liver
Half-life of ~ 2 days
Higher sensitivity to changes in proteinenergy 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.
Zinc supplementation offers no benefit if the
patient is not deficient
Zinc supplementation may interfere with copper
absorption
Stechmiller AK, Cowan L, Logan KM. Nutrition support for wound healing. Supp. Line.
2009;31(4):2-8.
Stechmiller AK, Cowan L, Logan KM. Nutrition support for wound healing. Supp. Line.
2009:31(4):2-8.
Hydration
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Adequate fluid is essential
 hydrate the wound site
 aid in oxygen perfusion
 transport 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
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Hypocholesterolemia
 < 160 g/dL
 With poor appetite and weight loss
suggests at nutritional risk
TLC
C-reactive protein
Pressure Ulcer Case
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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 breakfast
 Eats 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)
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PES Documentation
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Problem…
 related to (RT)…
Etiology…
 as evidenced by (AEB)…
Signs or symptoms
Nutrition Care Process & PES
Nutrition
Nutrition
Assessment Diagnosis
Problem
Etiology
Nutrition
Nutrition
Intervention Monitoring/
Evaluation
Sign/Symptoms