Transcript Malnutrition

Chapter 17:
Dysphagia and Malnutrition
Learning Objectives
• Assess for dysphagia at the bedside.
• Develop a plan to meet the nutritional and
hydration needs of a patient with dysphagia.
• Differentiate between anorexia of aging and
malnutrition.
• Describe the steps necessary to adequately assess
an older adult for malnutrition.
• Develop a plan to meet the nutritional needs of
a homebound older adult suffering from weight
loss and malnutrition.
Dysphagia
• Prevalence
– 25% and 30% of hospitalized patients
– 40–60% of persons in nursing homes
– Swallowing problems increase with age
• Implications
– Greater risk for nutritional deficiencies and
respiratory problems: aspiration pneumonia
– Dehydration and malnutrition predispose
persons to many medical problems
Dysphagia
• Warning signs/risk factors
– Oropharyngeal dysphagia usually related to
neuromuscular impairments affecting the
tongue, pharynx, and upper esophageal
sphincter
Coughing or choking with
swallowing
Difficulty initiating swallowing
Inability to control food or
saliva, Sialorrhea
Food sticking in the throat
Unexplained weight loss
Change in dietary habits
Recurrent pneumonia
Change in voice or speech
(wet voice)
Nasal regurgitation
Dysphagia
• Warning signs/risk factors
– Esophageal dysphagia results from motility
problems, neuromuscular problems, or
obstruction that interferes with the movement
of the food bolus through the esophagus into
the stomach
• Sensation of food sticking in the chest or throat
• Oral or pharyngeal regurgitation
• Change in dietary habits
• Recurrent pneumonia
Dysphagia
• Assessment
– Clinical evaluation of swallowing skills in
patients with conditions that predispose to
dysphagia or who voice complaints that suggest
a swallowing disorder should be a priority
for nursing
– 80% of dysphagia can be diagnosed through a
history- “how often do you cough after eating?”
– Cognitive, neuromuscular, and respiratory
assessment, plus medications
Dysphagia
• Interventions/strategies for care
– Diet modifications
• Dysphagia diet (pudding, honey thick, nectar thick..):
p. 629 table 17-3, p.630 Table 17-4
– Oral hygiene
– Adaptive equipment
• Interventions/strategies for care
– Managing Gastroesophageal Reflux Disease
• Avoid food or fluids associated with heartburn
or discomfort (coffee, spicy foods, fatty foods,
citrus fruits, alcohol, and smoking)
• Sitting up for at least an hour after eating and/or
raising the head of the bed 4 to 6 inches.
• Administer an oral proton pump inhibitor 60
minutes before a meal. (Lansoprazole,
Omeprazole, Pantoprazole)
• Interventions/Strategies for Care:
– Compensatory eating techniques
• Positioning - upright
• Establish arousal and attention
• Assist with head positioning
• Chin slightly tucked
• Do not rush
• Use small amounts of food - 1/2 teaspoons
• Place food on unaffected side
• Assist with lip closure if needed
• Interventions/Strategies for Care:
– Compensatory eating techniques (Cont.)
• Avoid use of straws (unless recommended by
speech therapist)
• Provide frequent verbal cues
• Use thickener for liquids as recommended (honey,
nectar, thin)
• Stimulate the swallowing reflex – oral care, menthol,
cold food, black pepper,…
• Educate person and family
• Thermal stimulation - cold stimulates the swallow
response
• Follow recommendations of speech therapist (may
have multiple steps)
• Non-oral interventions:
– G-tubes
– PEG tubes
• Percutaneous Endoscopic Gastrostomy (PEG) tube
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Check abdominal girth for distension
Check residual volumes
Keep upright after feedings
Monitor continually for aspiration
Treat GERD
Malnutrition
• Prevalence
– Anorexia of aging is a physiological process
that occurs with older age
• Increases the risk of developing malnutrition and
weight loss with a physical or psychological illness
– Malnutrition: a state of being poorly nourished
– Sarcopenia
• Syndrome of progressive and generalized loss of
skeletal muscle mass and strength
– Cachexia
• Associated with terminal illness
Malnutrition
• Implications
– Malnutrition can lead to
Delayed wound healing
Pressure ulcers,
Susceptibility to infections
Functional decline
Cognitive decline
Depression
Delayed recovery from acute
illness
Difficulty in swallowing\
dehydration
Decreased lean body mass
Lessened muscular strength
and aerobic capacity, leading
to chronic fatigue
Alterations in gait and balance,
increasing risk for falls and
fractures
Deterioration in their overall
quality of life and
dependence on others
Malnutrition
• Factors influencing nutritional risk
– Social
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Isolation
Loneliness
Poverty
Dependency
– Psychological
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Depression
Anxiety
Dementia
Bereavement
Malnutrition
• Factors influencing nutritional risk (cont’d)
– Biological
• Dentition
• Loss of taste or smell
• Gastrointestinal
disorders
• Muscle weakness
• Dry mouth
• Olfaction
Renal disease
Physical disability
Infections
Chronic obstructive
pulmonary disease
(COPD)
• Drug interactions
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Malnutrition
• Assessment
– Clinical screening tools: Mini Nutritional Assess
(MNA)
– Anthropometric and body composition measures:
Body Mass Index (BMI), serial body weight
– Laboratory assessments: Albumin (<3.5g/dl) and
prealbumin (<11mg/dl) level
– Clinical data review: current meds, oral problem, GI
problems, …
– Diet history review: check food consumed a day.
Malnutrition
• Evidence-based strategies to improve
nutrition
– Dietary supplements only for symptomatic
nutrient deficiency disease
– Real food is better than meal replacements
when possible
– USDA MyPlate method (figure 17-1, p. 641)
– Refer to other health care providers depending
on results of nutritional assessment
Summary
• Malnutrition in older adults is multifaceted and
complex. No single tool or clinical marker
accurately predicts nutritional status.
• A validated nutrition screening tool with
anthropometric and laboratory data can give a
more accurate picture of nutrition status.
• When reversible causes of malnutrition are
identified, evidence-based approaches should
be used, including referral to other disciplines.