Managing Malnutrition
Physicians, physician assistants, nurse practitioners, nurses, dietitians, and pharmacists are among the numerous healthcare professionals who manage malnutrition in patients (Table 2).2,21 Together, the team should develop a strategy that is specific and individualized for a given patient.2 The strategy should be compatible with the patient’s lifestyle, financial situation, and resources available for implementation.2,21 Regular evaluations using consistent nutritional parameters are imperative to ensure the best possible outcome is achieved.2 The patient’s healthcare team must communicate often and effectively to make certain an optimal plan is in place that maximizes patient adherence.12,21
Seven elements of patient management are advised for addressing malnutrition.
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Rehabilitation
Speech-language pathologists and physical and occupational therapists work directly with patients, family members, and caregivers to support overall nutritional intake. Speech-language pathologists assist in the evaluation, diagnosis, and treatment of communication (eg, language comprehension and expression) and dysphagia. Speech-language pathologist interventions may include use of specialized compensatory strategies, altering the patient’s diet, and training and education to improve safe eating and drinking.
Physical therapists assist in the evaluation, diagnosis, and treatment of functional limitations such as pain; decreased strength, endurance, and flexibility; poor balance; and insufficient postural control that can compromise the ability to effectively consume meals. Physical therapist interventions may involve exercises and activities that focus on the reduction of physical impairments to improve performance and functional mobility.
Occupational therapists evaluate and provide interventions that consider physical, cognitive, social, emotional, environmental, and cultural elements of feeding, eating, and swallowing. Occupational therapist interventions may focus on the reduction of positioning problems, psychosocial needs, and use of adaptive equipment that improve a patient’s ability and willingness to acquire nutrition.
Food-First Approach
This method is generally used as a first-line approach in patients who are deemed mildly malnourished or at risk for malnourishment and who do not have dysphagia.3 If a patient is unable to give reliable information regarding food and nutrient intake, this information should be obtained from a caregiver or another reliable source.21 This approach calls for 6 small meals to be eaten at approximately equal intervals throughout the day, and for individuals to have access to foods and beverages that meet their nutritional needs and taste preferences.2 Oil, butter, margarine, cream cheese, sauces, honey, and sugar may be added to foods to increase caloric content and improve taste.2 Plain water should be substituted with drinks with more nutritional content such as milk or juices.2 Food should look appealing and have a texture and taste that the individual is able to tolerate well.2 Meals should be consumed in a comfortable and relaxed environment to promote maximum food intake.2
Supplementation
For patients who are unable to consume enough protein and nutrients, oral drink supplements are an alternative source to aid in the achievement of daily nutritional requirements.2,18 A variety of different supplements provide a range of nutritional benefits including high energy, high protein, and high fiber; these should be chosen on the basis of individual need.2 Supplements come in many forms and flavors, and should be chosen based on the individual’s ability to properly prepare the supplement and taste preferences.2
Although results have not been conclusive, data from studies suggest that nutritional supplements be given at a midway point between meals for optimal results.2 The use of nutritional supplements should be regularly evaluated to ensure the patient is tolerating it well and receiving proper nutritional benefit.2 In the elderly, high-quality supplements have been shown to promote healthy aging and improve age-related problems and diseases.18
Exercise
A continuous program of physical activity including aerobic exercise and
resistance training can provide a broad range of physiologic benefits that help
maintain or improve overall functional mobility.22,23 Muscle mass is the largest reservoir of body
protein and its preservation is important for maintaining nutritional status
and physical function.24 Older malnourished patients are at increased
risk for muscle mass loss, and a combination of exercise and high protein
intake is recommended to help maintain and build these stores.18,24 Strength
exercise conducted 2 to 3 times per week over the course of 9 weeks has been
shown to be effective in increasing muscle mass in healthy to moderately
impaired individuals.24 Consuming a protein supplement directly after
exercise has been shown to increase the effect of exercise on muscle mass.18,24
Patients with serious disease complications or a recent catastrophic
event may not be able to tolerate exercise and should consult with a physician
before beginning a regimen.24
Medical Intervention
Appetite stimulants are rarely indicated to help patients achieve increased appetite because of interactions with other medications, resulting in unwanted adverse effects.2 Antidepressants can improve mood and overall well-being and increase the desire to eat and maintain health in elderly patients who demonstrate signs of depression.15 Dentures may be appropriate for individuals with poor dentition to increase the range of foods that can be easily consumed.19 Other pharmacologic therapy and medical interventions should be prescribed according to individual needs.
Food Services
Programs that provide food to the elderly have been shown to help prevent malnutrition and ensure nutritional needs are met. The Administration on Aging (AOA) provides communal and personal, home-delivered meals and other nutrition-related services to elderly individuals.25 The AOA stipulates that all meals generated with their funds must provide one-third of an individual’s daily nutritional requirements.25 The elderly nutrition program provides a range of other services including helping participants learn how to shop, save, and prepare meals that are economical and healthy.20 Volunteers and paid staff who deliver these meals often spend time with individuals to alleviate loneliness and to identify any additional unrecognized medical problems that should be reported to the appropriate provider.25
Prevention
As described earlier, malnutrition can lead to increased vulnerability to illness and poor clinical outcomes, and can increase mortality.2 Better outcomes can be achieved through preventive measures in at-risk individuals, rather than attempting to cure malnutrition after its onset. Elderly individuals who are not malnourished or who are at low risk for malnourishment should be regularly monitored for weight loss and screened for signs of malnutrition in an effort to decrease overall incidence. Clinicians should be aware of the signs and symptoms of malnutrition, along with the screening tests that help recognize and diagnose the condition, to prevent further progression.
James Haines, MPAS, PA-C, specializes in emergency medicine at Lake West Hospital in Willoughby, Ohio. David LeVan, DHSc, OTR/L, CSRS, is an associate professor in the Occupational Therapy Program at Gannon University in Erie, Pennsylvania. Michele M. Roth-Kauffman, JD, MPAS, PA-C, is the founding program director of the Physician Assistant Program at Gannon University in Ruskin, Florida.
References
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25. Administration for Community Living (ACL). Nutrition services. ACL website. https://acl.gov/programs/health-wellness/nutrition-services. Updated November 13, 2019. Accessed December 26, 2019.
