Disclosures. Learning Objectives 4/21/2015. Incorporating Nutrition-Focused Physician Assessment into Malnutrition Diagnosis. None

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1 Incorporating Nutrition-Focused Physician Assessment into Malnutrition Diagnosis Robert DeChicco MS, RD, LD, CNSC Manager, Nutrition Support Team Center for Human Nutrition Cleveland Clinic Health System, Cleveland, OH Maryland Academy of Nutrition and Dietetics 2015 Annual Meeting April 24, 2015 Linthicum Heights, MD Disclosures None Learning Objectives Identify methods for obtaining information used to support diagnosis of malnutrition Describe systematic approach to conducting nutrition-focused physical assessment Correlate evidence from different sources to determine etiology and degree of malnutrition 1

2 Diagnosing Malnutrition: Steps Determine Etiology: Social / Environmental Circumstances Chronic Illness Acute Illness or Injury Determine Characteristics: Insufficient Energy Intake, Weight Loss Muscle Loss, Fat Loss Fluid Accumulation, Functional Status Number of Characteristics Present <2 NO MALNUTRITION IDENTIFIED 2 MODERATE MALNUTRITION SEVERE PROTEIN CALORIE MALNUTRITION Obtaining Evidence of Malnutrition: Methods Method Source Information Review EMR Past medical/surgical history History of present illness Clinical course Past/current medications Lab and culture results Imaging studies, endoscopies Input/output records Vital signs, weights Interview Patient, family Diet history Weight history Functional status Examine Patient Fat/muscle loss Fluid accumulation Functional status Micronutrient deficiencies NFPA: Techniques Inspection visually examining the body using the eyes and a lighted instrument if needed Palpation feeling with the fingers or hands to examine the size, consistency, texture, location, and tenderness of an organ or body part 2

3 NFPA: Head-to-Toe Approach 1. GENERAL SURVEY 3. HEAD, NECK 5. ABDOMEN, RIBS, LOWER BACK 2. SKIN 4. CHEST, SHOULDERS, UPPER BACK 7. HIPS, THIGHS, KNEES 6. ARMS, HANDS 8. CALVES, FEET, ANKLES NFPA: Rules of Thumb Evaluate signs/symptoms in context of each patient s age, gender, and body type Evaluate findings compared with normal Fat/muscle loss in one area is usually present in all areas Subtle changes in fat/muscle loss difficult to detect Physical Exam Pocket Guide 3

4 NFPA: Mild-Moderate Wasting NFPA: Mild-Moderate Wasting NFPA: Mild-Moderate Wasting 4

5 Fluid Accumulation One of six characteristics Localized or generalized Non-pitting or pitting Chronic or acute Correlate with labs, vital signs, I/Os Most helpful in determining weight change Use with caution to support malnutrition Fluid Accumulation Fluid Status: Correlation of Physical Findings with Other Evidence Parameter Fluid Overload Dehydration Physical Exam Pitting edema Dry mucous membranes Tenting of skin Labs (serum) Na, Hgb, ALB Na, BUN, Cr, ALB, Hgb Input/Output UOP UOP Vital Signs HR, RR BP, HR Weight Increased Decreased 5

6 Functional Status One of six characteristics Difficult to measure Ability to perform ADLs, strength, energy, endurance Consider surrogate measurements Correlate timing of decline in function with other evidence Rule out non-nutritional causes NFPA Video Etiology-Based Malnutrition Guidelines Nutritional Risk Identified Compromised intake or loss of body mass. Jensen GL. JPEN 2009;33:710 Inflammation present? No / Yes No Yes Mild-to-moderate Yes Moderate-to-severe Malnutrition related to Social/Environmental Circumstances Chronic Disease Related Malnutrition Acute Illness or Injury- Related Malnutrition 6

7 Vital Signs: Interpretation Parameter Temperature Heart Rate Respiratory Rate Interpretation Normal: 37.0C/98.6F Fever: 37.7C/99.9F or >1 degree above normal Hypothermia: <35.0C/95.0F Normal: beats per minute Tachycardia: >100 beats per minute Bradycardia: <60 beats per minute Normal: breaths per minute Tachypnia: >20 breaths per minute Bradypnia: <12 breaths per minute Inflammation: Possible Signs & Symptoms Parameter Physical Exam Labs Cultures Vital Signs Imaging studies Endoscopies Sign/Symptom of Possible Inflammation Localized redness, swelling, tenderness/pain Productive cough, shaking chills, myalgias Open wounds, pressure ulcers Edema Drains, surgical incisions CRP, WBC, ALB, GLU Positive blood, urine, abdominal fluid, wound cultures Temperature, RR, HR Abscess, leak, fistula, pneumonia Ulcers, erythema, friable mucosa Possible Etiologies for Malnutrition Etiology Acute injury or illness Chronic disease Social/environmental circumstances Examples critical illness, major infection/sepsis, ARDS, SIRS, severe burns, major abdominal surgery, multi-trauma, closed head injury cardiovascular disease, CHF, cystic fibrosis, IBD, celiac disease, chronic pancreatitis, rheumatoid arthritis, COPD, solid tumors, hematologic malignancies, DM, sarcopenic obesity, metabolic syndrome, pressure wounds, neuromuscular disease, dementia, organ failure/transplant anorexia nervosa, major depression Jensen G, et al. JPEN 2012;36:

8 Determining Etiology for Malnutrition: Challenges Multiple diseases/conditions can occur simultaneously Acute exacerbations of chronic conditions Etiology can change during course of admission No definitions of mild-moderate vs severe inflammation Evidence of inflammation not always present Evidence of inflammation does not always support etiology Determining Etiology for Malnutrition: Guidelines Determine single disease/condition contributing the most to current episode of malnutrition Use past medical/surgical history, history of present illness, and clinical course Use evidence of inflammation to support, not determine, etiology Appropriate to justify more than one etiology for same patient Use clinical judgment Case Studies: Etiology 8

9 Case 1: Determine Etiology 47 year old female PMH: obesity, CAD, DM, COPD Admitted due to pneumonia>>>ards UBW: 178 lbs. No weight loss PTA - HD#3. NPO since admission - T38.2C, CRP, ALB, GLU - Weight: 192 lbs (bed scale) - 2+ lower extremity edema - No fat/muscle loss ACUTE ILLNESS OR INJURY Case 2: Determine Etiology 58 year old male PMH: HTN Weight loss: 8% past 6 months due to poor appetite Admitted due to intractable nausea and vomiting x 2 days Colonoscopy: near obstructing colon mass - HD#2. NPO since admission - T37.2C, HR 80, RR 12, BP 130/80 - WBC 10.8, ALB Mild fat/muscle loss - No edema CHRONIC DISEASE Case 3: Determine Etiology 58 year old male, PMH: HTN Weight loss: 8% past 6 months due to poor appetite Admitted due to intractable nausea and vomiting x 2 days Diagnosed with near obstructing colon cancer Elective surgery c/b abdominal abscess per CT abdomen. Drain placed. Culture positive. Start antibx - HD#4/POD#2 - NPO since admission - T38.5C, HR 112, RR 16, BP 120/80 - WBC 17.8, ALB Mild fat/muscle loss - 2+ lower extremity edema CHRONIC DISEASE 9

10 Case 4: Determine Etiology 77 year old female PMH: chronic malabsorption, dementia PSH: TAC, end ileostomy 20 years ago due to ischemic bowel Adm due to recurrent dehydration due to high ostomy output 5% weight loss past 1 week - HD#2, NPO - I/O: IV 2400 ml, UOP 750 ml, ostomy 3200 ml - Tmax 36.9C, Sodium, ALB, BUN - Severe fat/muscle loss - No edema, dry mouth SOCIAL/ENVIRONMENTAL CIRCUMSTANCES Case Studies: Characteristics and Supporting Evidence Case 1: Acute Illness or Injury 47 year old female PMH: obesity, CAD, DM Admitted/intubated due to pneumonia>>>ards UBW: 178 lbs. No weight loss PTA - T38.2C, CRP, ALB, GLU - NPO since admission (3 days) - Weight: 192 lbs (bed scale) - 2+ lower extremity edema - No fat/muscle loss 10

11 Case 1: Acute Illness or Injury Characteristics Non-severe / Moderate Severe Insufficient energy intake 75% for 7 days 50% for 5 days Unintentional weight loss Loss of subcutaneous fat Loss of muscle mass Fluid accumulation Diminished functional capacity 1-2% in 1 week 5% in 1 month 7.5% in 3 months Mild loss of subcutaneous fat Mild muscle wasting of temples (interosseous), scapula (latissimus dorsi, trapezius), thigh (quadriceps), calf (gastrocnemius) Mild generalized or localized No change >2% in 1 week >5% in 1 month >7.5% in 3 months Moderate loss of subcutaneous fat Moderate muscle wasting of temples (interosseous), scapula (latissimus dorsi, trapezius), thigh (quadriceps), calf (gastrocnemius) Moderate generalized or localized Decline in physiological function NO MALNUTRITION IDENTIFIED Case 2: Chronic Disease 58 year old male PMH: HTN Weight loss: 8% past 6 months due to poor appetite Admitted due to intractable nausea and vomiting x 2 days Colonoscopy: near obstructing colon mass - Hospital day #2 - NPO since admission - T37.2C, HR 80, RR 12, BP 130/80 - WBC 10.8, ALB Mild fat/muscle loss - No edema Case 2: Chronic Illness Characteristics Non-severe / Moderate Severe Insufficient energy intake <75% for 1 month 75% for 1 month Unintentional weight loss Loss of subcutaneous fat Loss of muscle mass Fluid accumulation Diminished functional capacity 5% in 1 month 7.5% in 3 months 10% in 6 months 20% in 1 year Mild loss of subcutaneous fat Mild muscle wasting of temples (interosseous), scapula (latissimus dorsi, trapezius), thigh (quadriceps), calf (gastrocnemius) Mild generalized or localized No change >5% in 1 month >7.5% in 3 months >10% in 6 months >20% in 1 year Severe loss of subcutaneous fat Severe muscle wasting of temples (interosseous), scapula (latissimus dorsi, trapezius), thigh (quadriceps), calf (gastrocnemius) Severe generalized or localized Decline in physiological function MODERATE MALNUTRITION 11

12 Case 3: Chronic Disease 58 year old male, PMH: HTN Weight loss: 8% past 6 months due to poor appetite Admitted due to intractable nausea and vomiting x 2 days Diagnosed with near obstructing colon mass Elective surgery c/b abdominal abscess per CT abdomen. Drain placed. Culture positive. Start antibx - HD#4/POD#2 - NPO since admission - T38.5C, HR 112, RR 16, BP 120/80 - WBC 17.8, ALB Mild fat/muscle loss - 2+ lower extremity edema Case 3: Chronic Illness Characteristics Non-severe / Moderate Severe Insufficient energy intake <75% for 1 month 75% for 1 month Unintentional weight loss Loss of subcutaneous fat Loss of muscle mass Fluid accumulation Diminished functional capacity 5% in 1 month 7.5% in 3 months 10% in 6 months 20% in 1 year Mild loss of subcutaneous fat Mild muscle wasting of temples (interosseous), scapula (latissimus dorsi, trapezius), thigh (quadriceps), calf (gastrocnemius) Mild generalized or localized No change MODERATE MALNUTRITION >5% in 1 month >7.5% in 3 months >10% in 6 months >20% in 1 year Severe loss of subcutaneous fat Severe muscle wasting of temples (interosseous), scapula (latissimus dorsi, trapezius), thigh (quadriceps), calf (gastrocnemius) Severe generalized or localized Decline in physiological function Case 4: Social/Environmental 77 year old female PMH: chronic malabsorption, dementia PSH: TAC, end ileostomy 20 years ago due to ischemic bowel Adm due to recurrent dehydration due to high ostomy output 5% weight loss past 1 week - HD#2, NPO - I/O: IV 2400 ml, UOP 750 ml, ostomy 3200 ml - Tmax 36.9C, Sodium, ALB, BUN - Severe fat/muscle loss - No edema, dry mouth 12

13 Case 4: Social/Environmental Characteristics Non-severe / Moderate Severe Insufficient energy intake Unintentional weight loss Loss of subcutaneous fat Loss of muscle mass Fluid accumulation Diminished functional capacity <75% for 1 month 75% for 1 month 5% in 1 month 7.5% in 3 months 10% in 6 months 20% in 1 year Mild loss of subcutaneous fat Mild muscle wasting of temples (interosseous), scapula (latissimus dorsi, trapezius), thigh (quadriceps), calf (gastrocnemius) Mild generalized or localized No change SEVERE PROTEIN-CALORIE MALNUTRITION >5% in 1 month >7.5% in 3 months >10% in 6 months >20% in 1 year Severe loss of subcutaneous fat Severe muscle wasting of temples (interosseous), scapula (latissimus dorsi, trapezius), thigh (quadriceps), calf (gastrocnemius) Severe generalized or localized Decline in physiological function Summary Obtain as much evidence of malnutrition from as many sources as possible Correlate available evidence to determine etiology and degree of malnutrition Presence or absence of evidence of inflammation does not rule out any etiology Use clinical judgment Questions? 13