1. Nutrition, Deconditioning and Frailty Janice Poon and Samantha King Aged Care/Rehabilitation Dietitians 8 May 2013

2. Summary Common nutritional issues in rehabilitation Co morbidities affecting nutritional status Malnutrition Screening and assessment of malnutrition Interventions for treating malnutrition

3. Common Reasons for Nutrition Intervention in Rehabilitation Poor oral intake, loss of appetite Loss of weight or underweight Malnutrition Requiring texture modified diet and/or thickened fluids (dysphagia or dentition) Hypermetabolic conditions (acute illness, cancer, pressure injuries)

4. Common Reasons for Nutrition Intervention in Rehabilitation Renal insufficiency – protein, K +, Na +, PO 4, fluid Diabetes – newly dx, change of meds/insulin, hypos, unstable Requiring education re: managing fluid restriction (CCF, renal, liver) Gastrointestinal disease or symptoms CVD risk reduction Obesity

5. Co-morbidities Impacting Nutritional Status in Rehabilitation Stroke –Many factors effect nutritional status after stroke (dysphagia, fatigue, decreased physical function, psychological i.e.: depression) –Dietary inadequacy is common after stroke 1 –Early feeding after stroke is important –Significant association between energy intake in early stages of admission after stroke and the rate of function recovery 1 –Timely nutrition intervention important 1 Nip W. F.R., et al. Dietary intake, nutritional status and rehabilitation outcome of stroke patients in hospital. J Hum Nutr Diet 2011; 24: 460-469

6. Dysphagia Consequences of Dysphagia: –Dehydration: most common issue due to lack of available thickened fluids, or the patient’s dislike of them –Malnutrition: Due to dislike of texture-modified diets and/or thickened fluids or difficulty consuming adequate quantities. 2012 study of Austin patients indicate 50% patients receiving thickened fluids are malnourished. 20% severely malnourished.

7. Dysphagia and Fluid Intake Study at Austin Health 2009

8. Acute Illness (eg. pneumonia, UTI) Causes an increased requirement for nutrients due to increased immune system activity Some acute illnesses (eg. wounds or GI bleeding) can cause a loss of nutrients, further increasing requirements Symptoms of illness result in the patient eating less (eg. fever, delirium, nausea/vomiting, diarrhoea, etc.) Double edged sword – patients need more nutrients but are eating less than normal Can result in rapid loss of weight (esp. muscle) and deconditioning

9. Chronic Diseases (eg. CVD, diabetes, etc.) Elderly/frail are more likely to struggle to self-manage their illness due to: –Decreasing physical function (eg. loss of vision, strength, etc) –Decreasing cognitive function (to perform self-monitoring) –Increasing complexity of medical conditions (multiple co- morbidities) –Complications of chronic diseases appear (eg. neuropathy, APO, etc.)

10. Cancer Significantly increases nutritional requirements (1.2-1.5 X basal metabolic rate) Symptoms of illness and side effects of treatments reduces ability to eat Large weight loss/de-conditioning common Alternative therapies often promote low calorie diets that worsen de-conditioning Increased risk of malnutrition

11. Pressure Injuries and Wounds Complications: pain, discomfort, ↓ mobility, greater reliance on nursing staff, ↑ LOS, increased mortality Risk factors: malnutrition, dehydration, recent weight loss Significant increase of requirements for wound healing (1.2-1.5 X basal metabolic rate) Recent studies at Austin (2010, 2011, 2012) indicate that 50% of patients with a pressure injury are malnourished

12. Pressure Injuries and Wounds Specific nutrients involved in wound healing include: protein (especially the amino acid arginine), vitamin C and zinc Austin use specially formulated products such as Arginaid 66% decrease in healing time for patients with stage 2 or greater pressure injuries when used for 3 weeks 2 2 Desneves KJ, Todorovic BE, Cassar A & Crowe TC. Treatment with supplementary arginine, vitamin C and zinc in patients with pressure ulcers: a randomised controlled trial. Clin Nutr 2005; 24:979-87.

13. Malnutrition “A state of nutrition in which a deficiency or excess (or imbalance) of energy, protein, and other nutrients causes measurable adverse effects on tissue/body form (body shape, size and composition) and function and clinical outcome”. 3 The most common nutritional disorder encountered in aged care. Occurs in 30-50% of patients in rehabilitation settings in Australia 4 Austin Health 2011 549 patients were assessed across the organisation 46% (n=253) malnourished 36% mildly- moderately malnourished (n=200) and 10% severely malnourished(n=53) 3 Elia M, editor Guidelines for detection and management of malnutrition. Malnutrition Advisory Group Maidenhead: BAPEN, 2000 4 Tapsell L, editor Evidence Based Practice Guidelines for the Nutritional Management of Malnutrition in Adult Patients Across the Continuum of Care, Nutrition & Dietetics 2009: 66 s3: S4.

14. Types of Malnutrition Protein-energy malnutrition –The most common, results in loss of weight (fat and muscle mass) and is a major cause of functional decline in the elderly Micronutrient malnutrition –Deficiency of a particular vitamins or minerals that may cause specific symptoms or illness (eg. iron deficiency anaemia, osteoporosis, etc.)

15. Malnutrition Nutrition status deteriorates in a significant proportion of individuals over the course of admission in the rehabilitation setting. 4 Has a large impact on physical and cognitive function. 4 Associated with adverse clinical outcomes and increased costs in the rehabilitation setting. 4 Malnutrition and decreased oral intake in hospital has long-term effects even after discharge home (6 months). 5 Is under-recognised and under diagnosed in the rehabilitation setting. 4 Malnutrition is often chronic and multi-factorial. 4 4 Tapsell L, editor Evidence Based Practice Guidelines for the Nutritional Management of Malnutrition in Adult Patients Across the Continuum of Care, Nutrition & Dietetics 2009: 66 s3: S4. 5 Moss C., et al. Gastrointestinal Hormones: the regulation of appetite and the anorexia of ageing. J Hum Nutr Diet 2011; 25:3-15

16. Malnutrition in the Developed World Not that different to a developing country

17. Reasons for Malnutrition in the Elderly Cognitive impairment (including dementia and delirium) Polypharmacy (early satiety from multiple medications + water) Depression Natural decline in hunger and thirst with ageing Living situations, cooking facilities, transport options Poverty Food security/access to food Social Isolation Disability Misinformation/poor food knowledge

18. Common Reasons for Malnutrition in Rehabilitation Patients Dislike of hospital food Dysphagia Reduced sense of smell & taste (25% of adults over 65 have reduced taste) Decreased dexterity/physical ability (packaging, self feeding) Increased nutritional requirements not meet (acute illnesses, cancer, pressure injuries) Poor dentition or mouth care

19. Consequences of Malnutrition Medical : –Can exacerbate oedema and respiratory problems 4 –Severely delays wound healing 4 –Compromises immune function and increases infection rates 4 –Increase mortality 4 Dehydration can worsen renal function and cognition 4 Tapsell L, editor Evidence Based Practice Guidelines for the Nutritional Management of Malnutrition in Adult Patients Across the Continuum of Care, Nutrition & Dietetics 2009: 66 s3: S4.

20. Consequences of Malnutrition Physical: –Decreased muscle mass/strength –Reduced bone strength –Reduced ability to participate in rehabilitation “Greater than10% weight loss over 2 years is associated with a 2-3 times higher risk of limitation in physical function and mobility, even after controlling for smoking, disease status and BMI at baseline.” 6 6 Bannerman et al. Anthropometric indices predict physical function and mobility in older Australians: The Australian Longitudinal Study of Ageing. Public Health Nutr 2002; 5 (5): 655-662.

21. Consequences of Malnutrition Cognitive: –Reversible cause of reduced cognitive function, diminishing a patient’s insight, orientation, memory and learning capacity Effect on nursing care: –Deconditioning increases the level of dependence on nursing staff/carers with transfers, toileting, etc. –Reversing malnutrition could make the difference between continence/incontinence, need for particular wound dressings, difficult transfers, etc.

22. Costs of Malnutrition: Financial ~$38 million per year for Australia of which $13million from pressure areas 7,8 Increased rehab time Poor/delayed wound healing Increased acute illness Increased LOS 9 7 Lim S, et al, Malnutrition and its impact on cost of hospitalization, length of stay, readmission and 3-year mortality. Clinical Nutrition. 2011; 11; 001 8 Banks M, et al, The costs arising from pressure ulcers attributable to malnutrition. ESPEN congress presentation 2007 9 Agarwal E, et al, Malnutrition and poor food intake are associated with prolonged hospital stay, frequent readmissions, and greater in-hospital mortality Clinical Nutrition 2012; 11; 21

23. Costs of Malnutrition: Quality of Life Quality of life for patients - delayed wound healing - decreased mobility - increased LOS (11 days) - increased reliance on nursing staff & decreased independence - Increase chance of discharge to residential care 10 The incidence of mortality 1yr after acute admission was nearly three times higher in malnourished patients 11 >5% LOW = twice as likely to die within 4 years regardless of initial weight 12 9 King C, et al, The predictive validity of the MUST with regard to mortality and length of stay in elderly inpatients. Clinical Nutrition. 2003; 22 S1, 4 10 King C. et al. 2003. The predictive validity of the malnutrition universal screening tool (MUST) with regard to mortality and length of stay in elderly inpatients. Clinical Nutrition, 22: Supp1 1, S4. 11 Middleton, M. Nazarenko, G. Nivison ‑ Smith, I. and Smerdely, P. 2001. Prevalence of malnutrition and 12 ‑ month incidence of mortality in two Sydney teaching hospitals. Internal Medicine Journal, 1:455 ‑ 461. 12 Newman JAGS 2001:1309 CV Health Study

24. Malnutrition How do you screen or assess for malnutrition?

25. How to screen for Malnutrition? Screening tools include: –Malnutrition Screening Tool (MST) –Malnutrition Universal Screening Tool (MUST) –Mini Nutritional Assessment-Short Form (MNA-SF) –Nutritional Risk Screening (NRS-2002) –Simplified Nutritional Assessment Questionnaire (SNAQ). eMUST available at Austin and Risk Assessment Tool includes screening information (2005 Audit – 10% pt’s weighed on admission at Austin)

26. MUST (Malnutrition Universal Screening Tool) Developed by Malnutrition Advisory Group (committee of British Association for Parental and Enteral Nutrition – BAPEN) Multidisciplinary group of health professionals Validated in all adult patient groups In hospital, predictor of length of stay, discharge destination and mortality (in the community, predictor of hospital admission and GP visits) e-MUST available at Austin Health (via Medtrak)

27. MUST

28. MNA Screening and assessment tool Validated in elderly population (only) Quick screening tool

29. Screening for Malnutrition Risk (RAT) Includes validated screening tool for identification of patients at risk of malnutrition –Has patient been screened using e-MUST? »Yes »No –Has patient lost weight without trying? »Yes »No »Don’t know –How much weight have they lost? »5kg or less »More than 5kg »Don’t know –Has patient been eating poorly because of decreased appetite? Includes referral to dietitian for patients with pressure injury

30. How to diagnose malnutrition Assessment tools include: –Subjective Global Assessment (SGA) –Patient Generated Subjective Global Assessment (PG-SGA) –Mini Nutritional Assessment (MNA)

31. SGA (Subjective Global Assessment)

32. Differences in assessment tools SGA: –Validated in adult populations –Combines physical assessment, oral intake, anthropometry and functional and clinical components. –Need to be trained to use this tool PG-SGA: –Provides a score and is sensitive to gradual changes on re- assessment. Validated for oncology and renal population only MNA –Requires detailed knowledge of quality of intake –Less detailed physical examination

33. Other Components of Nutritional Assessment Can quantify nutritional status with surrogate markers: –Anthropometry: weight, BMI, other measures (such as mid- upper arm circumference) –Biochemistry (Alb, pre-albumin, micronutrients) –Clinical condition –Nutritional intake –Nutritional requirements –Hand grip strength –Bioimpedance –Skin folds Look at not only what someone’s nutritional issue is, but why it has occurred

34. Benefits of Screening & Assessing Malnutrition Identification, documentation and coding of malnutrition results in a favourable reimbursement under casemix funding. 4 Nutrition interventions in malnourished patients [is] associated with improved nutrition status, nutrient intake, physical function, quality of life and a reduction of hospital readmissions. 13 4 Tapsell L, editor Evidence Based Practice Guidelines for the Nutritional Management of Malnutrition in Adult Patients Across the Continuum of Care, Nutrition & Dietetics 2009: 66 s3: S4. 13 Mueller C et al A.S.P.E.N. Clinical Guidelines: Nutrition Screening, Assessment, and Intervention in Adults, J Parenter Enteral Nutr 2011: 35: 16.

35. Interventions for Undernourished and Malnourished Oral nutrition support Enteral nutrition Parenteral nutrition Change of hospital diet/menu Increase of support staff Education Medpass Protected meal times

36. Medpass Program 60-120mL QID of energy/protein dense supplement or arginaid powder sachet + water Energy/protein dense supplement contains 2000KJ, 20g protein, 21g fat, 51g CHO (equivalent to main meal + dessert) Initially trialled in US nursing homes in 1990s Monash Medical Centre commenced trial in 2000. 50% patients gained weight, 95% at least stabilised weight Reduced incidence of pressure injuries Other studies found reduced supplement waste, improved appetite and meal consumption

37. Protected Meal Times Protected mealtimes is a strategy to reduce interruptions and maximise assistance at mealtimes to enhance a patient’s opportunity to eat. It has successfully been implemented across many acute and sub-acute facilities in England and became a NHS national programme in 2004. Many studies have detailed benefits like: the wards being calmer and more patient focused, weight gain in patients, reduced food wastage, decrease in food complaints and reduced length of stay.

38. Protected Mealtimes Initial Observations on Austin Rehabilitation Ward Austin by Design framework. 34 observations of lunch time (2040 minutes). 32/34 (95% of patients experienced interruptions ranging from 1-46 minutes.

39. Interventions Main barriers were identified and interventions tailored to improve meal access for patients. These included: Staff, patients and visitors educated regarding protected mealtimes. Timing for lunch delivery deferred by 15 minutes to enable patients at therapy to return in time for lunch. Alternative, easier to open packaging was sourced to replace juice and bread containers.

40. Results 45% (9/20) of patients were interrupted, representing a decrease of nearly 50%. The maximum interruption time decreased from 46 minutes to 7 minutes (range 1-7 minutes).

41. Questions?