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Labs: Indicators for Nutritional Intervention

Labs: Indicators for Nutritional Intervention. Suzanne Neubauer, PhD, RD, CNSD Framingham State University MA DHCC Conference September 30, 2010. Overview. Disease States/Conditions E vidence of malnutrition P ressure ulcers Diabetes Anemia Nutrition Care Process Nutrition Diagnosis

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Labs: Indicators for Nutritional Intervention

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  1. Labs: Indicators for Nutritional Intervention Suzanne Neubauer, PhD, RD, CNSD Framingham State University MA DHCC Conference September 30, 2010

  2. Overview • Disease States/Conditions • Evidence of malnutrition • Pressure ulcers • Diabetes • Anemia • Nutrition Care Process • Nutrition Diagnosis • Labs • Intervention

  3. female gender cognitive decline loss of appetite swallowing problems low activity level eating dependency recent hospitaliz-ation and admission to healthcare communities What is the evidence to support a relationship between nutritional status and increasing age? • Grade I: Good • evidence or risk of malnutrition, declining nutritional status and adverse health effects was associated with http://www.adaevidencelibrary.com/conclusion.cfm?conclusion_statement_id=251257

  4. 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

  5. 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

  6. 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

  7. Seven Criteria for Establishing the Value of Screening Procedures Holmes, S. (2000) “Nutritional screening and older adults.” Nursing Standard15(2):42-44.

  8. 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.

  9. Mini Nutritional Assessment (Full Form) • http://www.mna-elderly.com/mna_forms.html

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

  11. MM Nestle Mini Nutritional Assessment MNA Cont’d Anthony PS, Nutr Clin Pract. 2008;23:373-382.

  12. Mini-Nutritional Assessment-Short Form (SF) • Overview • http://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

  13. DETERMINE Your Nutritional Health • 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)

  14. DETERMINE Your Nutritional Health • 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)

  15. 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)

  16. 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)

  17. 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)

  18. 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)

  19. 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)

  20. 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)

  21. 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)

  22. 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)

  23. 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)

  24. 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..

  25. 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

  26. 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

  27. Malnutrition • When biochemical indicators are not available, is MNA enough?

  28. What about Protein Levels? • 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

  29. 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 Acute-Phase Proteins Jensen GL, JPEN 2006;30:453-463

  30. 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.

  31. 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

  32. 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.

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

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

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

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

  37. 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.

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

  39. Hydration • 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

  40. Other Labs • Hypocholesterolemia • < 160 g/dL • With poor appetite and weight loss suggests at nutritional risk • TLC • C-reactive protein

  41. 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 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

  42. 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)

  43. PES Documentation • Problem… • related to (RT)… • Etiology… • as evidenced by (AEB)… • Signs or symptoms

  44. Nutrition Care Process & PES Problem Etiology Sign/Symptoms

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