Reprinted with permission from Springer Publishing Company. Evidence-Based Geriatric Nursing Protocols for Best Practice, 4th Edition, © Springer Publishing Company, LLC. These protocols were revised and tested in NICHE hospitals. The text is available here.
The information in this "Want to know more" section is organized according to the following major components of the NURSING PROCESS:
Improvement in indicators of nutritional status in order to optimize functional status and general well-being and promote positive nutritional status.
Older adults are at risk for malnutrition, with 39% to 47% of hospitalized older adults malnourished or at risk for malnutrition (Ref 1).
1. Malnutrition: Any disorder of nutritional status, including disorders resulting from a deficiency of nutrient intake, impaired nutrient metabolism, or over-nutrition.
B. Etiology and/or Epidemiology. Older adults are at risk for under-nutrition due to dietary, economic, psychosocial, and physiological factors (Ref 2).
1. Dietary intake
a. Little or no appetite (Ref 3; 4 ; 5)
b. Problems with eating or swallowing (Ref 6).
c. Eating inadequate servings of nutrients (Ref 6).
d. Eating fewer than two meals a day (Ref 5).
2. Limited income may cause restriction in the number of meals eaten per day or dietary quality of meals eaten. 6
a. Older adults who live alone may lose desire to cook because of loneliness. 7
b. Appetite of widows decreases. 7
c. Difficulty cooking due to disabilities. 6
d. Lack of access to transportation to buy food (Ref 2).
4. Chronic Illness
a. Chronic conditions can affect intake (Ref 6).
b. Disability can hinder ability to prepare or ingest food (Ref 5).
d. Poor oral health (e.g., cavities, gum disease, and missing teeth) and xerostomia, or dry mouth, impairs ability to lubricate, masticate, and swallow food (Ref 5).
e. Antidepressants, antihypertensives, and bronchodilators can contribute to xerostomia (dry mouth) (Ref 2).
5. Physiological changes
b. Change in taste (from medications, nutrient deficiencies, or tastebud atrophy) can also alter nutritional status (Ref 2).
A. General: During routine nursing assessment, any alterations in general assessment parameters that influence intake, absorption, or digestion of nutrients should be further assessed to determine if an older adult is as nutritional risk. These parameters include the following:
1. Subjective assessment, including present history, assessment of symptoms, past medical and surgical history, and co-morbidities. 12.
2. Social history. 12
3. Drug–nutrient interactions: Drugs can modify the nutrient needs and metabolism of older people. Restrictive diets, malnutrition, changes in eating patterns, alcoholism, and chronic disease with long-term drug treatment are some of the risk factors in older adults that place them at risk for drug–nutrient interactions. 13.
4. Functional limitations. 14
5. Psychological status (Ref 14)
6. Objective assessment: physical examination with emphasis on oral exam (see Oral Health Care topic at www.ConsultGeriRN.org), loss of subcutaneous fat, muscle wasting, BMI12 and dysphagia.
B. Dietary Intake: in-depth assessment of dietary intake during hospitalization may be documented with a 3-day calorie count (dietary intake analysis).(Ref 2)
C. Nutrition Risk Assessment Tool: The Mini-Nutritional Assessment (MNA) should be administered to determine if an older hospitalized patient is either at risk for malnutrition or has malnutrition. The MNA determines risk based on food intake, mobility, BMI, history of weight loss, psychological stress, or acute disease and dementia or other psychological conditions. If the score is 11 points or less, the in-depth MNA assessment should be administered (Ref 15).
1. Obtain an accurate weight and height through direct measurement. Do not rely on patient recall. If patient cannot stand erect to measure height, then knee-height measurements should be taken to estimate height using special knee-height calipers. Height should never be estimated or recalled, due to shortening of the spine with advanced age; self-reported height may be off by as many as 2.4 cm (Ref 15).
2. Weight history: A detailed weight history should be obtained along with current weight. Detailed history should include a history of weight loss, whether the weight loss was intentional or unintentional, and during what period. A loss of 10 pounds during a 6-month period, whether intentional or unintentional, is a critical indicator for further assessment (Ref 2; 16).
3. Calculate body mass index (BMI) to determine if weight for height is within the normal range of 22–27. A BMI below 22 is a sign of under-nutrition (Ref 16).
E. Visceral Proteins. Evaluate serum albumin, transferrin, and prealbumin are visceral proteins commonly used to assess and monitor nutritional status (Ref 2). However, these proteins are negative acute-phase reactants; therefore, during a stress state, production is usually decreased. In an older hospitalized patient, albumin levels may be a better indicator of prognosis than nutritional status (Ref 17).
1. Refer to dietitian if patient is at risk for or has under-nutrition.
2. Consult with pharmacist to review patient's medications for possible drug–nutrient interactions.
3. Consult with a multidisciplinary team specializing in nutrition.
4. Consult with social worker, occupational therapist, and speech therapist as appropriate.
B. Alleviate Dry Mouth
1. Avoid caffeine; alcohol; tobacco; and dry, bulky, spicy, salty, or highly acidic foods.
2. If patient does not have dementia or swallowing difficulties, offer sugarless hard candy or chewing gum to stimulate saliva.
3. Keep lips moist with petroleum jelly.
4. Encourage frequent sips of water.
C. Maintain adequate nutritional intake: Daily requirements for healthy older adults include 30 kcal per kg of body weight and 0.8 to 1g/kg of protein per day, with no more than 30% of calories from fat. Caloric, carbohydrate, protein, and fat requirements may differ depending on degree of malnutrition and physiological stress.
D. Improve oral intake
1. Assess each patient's ability to eat within 24 hours of admission. (Ref 18)
2. Mealtime rounds to determine how much food is consumed and whether assistance is needed. (Ref 18)
3. Limit staff breaks to before or after patient mealtimes to ensure adequate staff are available to help with meals. (Ref 18)
4. Encourage family members to visit at mealtimes.
5. Ask family to bring favorite foods from home when appropriate.
6. Ask about and honor patient food preferences.
7. Suggest small frequent meals with adequate nutrients to help patients regain or maintain weight. (Ref 19)
8. Provide nutritious snacks. (Ref 19)
9. Help patient with mouth care and placement of dentures before food is served. (Ref 18)
E. Provide conducive environment for meals
1. Remove bedpans, urinals, and emesis basin from room before mealtime.
2. Administer analgesics and antiemetics on a schedule that will diminish the likelihood of pain or nausea during mealtimes.
3.Serve meals to patients in a chair if they can get out of bed and remain seated.
4. Create a more relaxed atmosphere by sitting at the patient’s eye level and making eye contact during feeding.
5. Order a late food tray or keep food warm if patients are not in their room during mealtime.
6. Do not interrupt patients for round and nonurgent procedures during mealtimes.
F. Specialized nutritional support. (Ref 20)
1. Start specialized nutritional support when a patient cannot, should not, or will not eat adequately and if the benefits of nutrition outweigh the associated risks.
2. Prior to initiation of specialized nutritional support, review the patient's advanced directives regarding the use of artificial nutrition and hydration.
G. Provide oral supplements
1. Supplements should not replace meals but rather be provided between meals but not within the hour preceding a meal and at bedtime. (Ref 19, 21)2. Ensure that oral supplement is at appropriate temperature. (Ref 19)
3. Ensure that oral supplement packaging is able to be opened by the patients. (Ref 19)
4. Monitor the intake of the prescribed supplement. (Ref 19)
5. Promote a sip style of supplement consumption. (Ref 19)
6. Include supplements as part of the medication protocol. (Ref 19)
H. N.P.O. orders
1. Schedule older adults for test or procedures early in the day to decrease the length of time they are not allowed to eat and drink.
2. If testing late in the day is inevitable, ask physician whether the patient can have an early breakfast.
3. See American Society of Anesthesiologists practice guideline regarding recommended length of time patients should be kept N.P.O. for elective surgical procedures. (Ref 22)
1. Will experience improvement in indicators of nutritional status.
2. Will improve functional status and general well-being.
1. Should ensure that care provides food and fluid of adequate quantity and quality in an environment conducive to eating, with appropriate support (e.g., modified eating aids) for people who can potentially chew and swallow but are unable to feed themselves. (Ref 16)
2. Should continue to reassess patients who are malnourished or at risk for malnutrition. (Ref 16)
3. Should monitor for refeeding syndrome. (Ref 16)
1. Will ensure that all health care professionals who are directly involved in patient care receive education and training on the importance of providing adequate nutrition. (Ref 16)
1. Establish QA/QI measures surrounding nutritional management in aging patients.
1. Provider education and training includes the following:
a. nutritional needs and indications for nutrition support
b. options for nutrition support (oral, enteral, and parenteral)
c. ethical and legal concepts
d. potential risks and benefits
e. when and where to seek expert advice (Ref 16)
2. Patient and/or caregiver education includes how to maintain or improve nutritional status, as well as how to administer, when appropriate, oral liquid supplements, enteral tube feeding, or parenteral nutrition.
A. Monitor for gradual increase in weight over time.
1. Weigh patient weekly to monitor trends in weight.
2. Daily weights are useful for monitoring fluid status.
B. Monitor and assess for refeeding syndrome.
1. Carefully monitor and assess patients the first week of aggressive nutritional repletion.
2. Assess and correct the following electrolyte abnormalities: Hypophosphatemia, hypokalemia, hypomagnesemia, hyperglycemia, and hypoglycemia.
3. Assess fluid status with daily weights and strict intake and output.
4. Assess for congestive heart failure in patients with respiratory or cardiac difficulties.
5. Ensure caloric goals will be reached slowly more than 3 to 4 days to avoid refeeding syndrome when repletion of nutritional status is warranted.
6. Be aware that refeeding syndrome is not exclusive to patients started on aggressive artificial nutrition but may also be found in elderly individuals with chronic co-morbid medical conditions and poor nutrient intake started with aggressive nutritional repletion via oral intake.
A. American Society of Anesthesiologists (1999). Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: Application to health patients undergoing elective procedures. Anesthesiology, 90, 896–905.
B. National Collaborating Centre for Acute Care (2006). Nutrition support in adults: Oral nutrition support, enteral tube feeding and parenteral nutrition. London, UK: National Institute for Health and Clinical Excellence (NICE). Clinical guideline no. 32. Electronic copies: Available in PDF format from that National Institutes for Health and Clinical Excellence (NICE) Web site.
C. American Society for Parenteral and Enteral Nutrition (2002). Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. Journal of Parenteral and Enteral Nutrition, 26, 1SA–138SA. (Note: These guidelines are undergoing revision.)
D. University of Texas, School of Nursing (2006). Unintentional weight loss in the elderly. Austin, TX: University of Texas, School of Nursing. (Note: These guidelines are located at www.guidelines.gov. However, the companion document with full bibliography is not in the public domain.)
Reprinted with permission from Springer Publishing Company. DiMaria-,Ghalili R.A. (2008). Nutrition in aging. In E. Capezuti, D. Zwicker, M. Mezey, & T. Fulmer (Eds.), Evidence-based geriatric nursing protocols for best practice. (3rd ed.). (pp. 353-367). New York: Springer Publishing Company, Inc.
1. Kaiser, M.J., Bauer, J.M., Rämsch, C., Uter, W., Guigoz, Y., Cederholm, T.,...Siber, C.C. (2010). Frequency of malnutrition in older adults: A multinational perspective using the mini nutritional assessment. Journal of the American Geriatrics Society, 58, 1734-1738. doi:10.1111/j.1532-5415.2010.03016.x. Evidence Level I.
3. Carlsson, P., Tidermark, J., Ponzer, S., Soderqvist, A., & Cederholm, T. (2005). Food habits and appetite of elderly women at the time of a femoral neck fracture and after nutritional and anabolic support. Journal of Human Nutrition and Dietetics, 18, 117–120. Evidence Level II: Individual Experimental Study.
4. Reuben, D. B., Hirsch, S. H., Zhou, K., & Greendale, G. A. (2005). The effects of megestrol acetate suspension for elderly patients with reduced appetite after hospitalization: A phase II randomized clinical trial. Journal of the American Geriatrics Society, 53, 970–975. Evidence Level II: Individual Experimental Study.
5. Saletti, A., Johansson, L., Yifter-Lindgren, E., Wissing, U., Osterberg, K., & Cederholm, T. (2005). Nutritional status and a 3-year follow-up in elderly receiving support at home. Gerontology, 51, 192–198. Evidence Level IV: Nonexperimental Study.
6. Margetts, B. M., Thompson, R. L., Elia, M., & Jackson, A. A. (2003). Prevalence of risk of under-nutrition is associated with poor health status in older people in the UK. European Journal of Clinical Nutrition, 57, 69–74. Evidence Level IV: Nonexperimental Study.
7. Souter, S., & Keller, C. (2002). Food choice in the rural-dwelling older adult. Southern Online Journal of Nursing Research, 5(3). Retrieved August 1, 2004, from http://www.snrs.org/publications/SOJNR_articles/iss05vol03.pdf. Evidence Level IV: Nonexperimental Study.
8. Kagansky, N., Berner, Y., Koren-Morag, N., Perelman, L., Knobler, H., & Levy, S. (2005). Poor nutritional habits are predictors of poor outcome in very old hospitalized patients. American Journal of Clinical Nutrition, 82, 784-791. Evidence Level IV.
9. Morley, J. E. (2001). Anorexia, sarcopenia, and aging. Nutrition, 17(7–8), 660–663. Evidence Level V: Narrative Literature Review.
10. Thomas, D. R., Zdrowski, C. D., Wilson, M, Conright, K. C., Lewis, C., Tariq, S., et al. (2002). Malnutrition in subacute care. American Journal of Clinical Nutrition, 75, 308–313. Evidence Level IV: Nonexperimental Study.
11. Janssen, I., Heymsfield, S. B., Allison, D. B., Kotler, D. P., & Ross, R. (2002). Body mass index and waist circumference independently contribute to the prediction of nonabdominal, abdominal, subcutaneous, and visceral fat. American Journal of Clinical Nutrition, 75, 683–688. Evidence Level IV: Nonexperimental Study.
12. University of Texas, School of Nursing (2006). Unintentional weight loss in the elderly. Austin, TX: University of Texas, School of Nursing. (Note: These guidelines are located at www.guidelines.gov. However, the companion document with full bibliography is not in the public domain.)
13. National Collaborating Centre for Acute Care (2006). Nutrition support in adults: Oral nutrition support, enteral tube feeding and parenteral nutrition. London, UK: National Institute for Health and Clinical Excellence (NICE). Clinical guideline no. 32. Electronic copies: Available in PDF format from that National Institutes for Health and Clinical Excellence (NICE) Website.
14. Pichard, C., Kyle, U.G., Morabia, A., Perrier, A., Vermeulen, B., & Unger, P. (2004). Nutritional assessment: Lean body mass depletion at hospital admission is associated with an increased length of stay. The American Journal of Clinical Nutrition, 79, 613-618. Evidence Level IV.
15. Guigoz, Y., Lauque, S., & Vellas, B.J. (2002). Identifying the elderly at risk for malnutrition. The Mini Nutritional Assessment. Clinics in Geriatric Medicine, 18,737-757. Evidence Level V.
16. Boullata, J. (2004) Drug-nutrient interactions. In P.H. Worthington, Practical aspects of nutritional support: An advanced practice guide (pp. 431–454). Philadelphia: Saunders. Evidence Level VI: Expert Opinion.
17. Salva, A., Corman, B., Andrieu, S., Salas, J., Vellas, B., and the International Association of Gerontology/International Academy of Nutrition and Aging (IAG/IANA) Task Force (2004). Minimum data set for nutritional intervention studies in elderly people. Journal of Gerontology: Medical Sciences, 59A, 724–729. Evidence Level V: Narrative Literature Review.
18. Jeffries, D., Johnson, M., & Ravens, J. (2011). Nurturing and nourishing: The nurses' role in nutritional care. Journal of Clinical Nursing, 20, 317-330. Evidence Level I.
19. Capra, S., Collins, C., Lamb, M., Vanderkroft, D., & Wai-Chi, S. (2007). Effectiveness of interventions for undernourished older patients in the hospital setting. Best Practice, 11, 1-4. Evidence Level I.
20. American Society for Parenteral and Enteral Nutrition (2002). Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. Journal of Parenteral and Enteral Nutrition, 26, 1SA–138SA. (Note: These guidelines are undergoing revision.)
21. Wilson, M. G., Purushothaman, R., & Morley, J. E. (2002). The effect of liquid dietary supplements on energy intake in the elderly. American Journal of Clinical Nutrition, 75, 944–947. Evidence Level IV: Nonexperimental Study.
22. American Society of Anesthesiologists (1999). Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: Application to health patients undergoing elective procedures. Anesthesiology, 90, 896–905.
Last updated - July 2012