Is Adult Malnutrition a Precursor to Pressure Ulcers? 1 Objectives Learn how to accurately determine whether an adult has malnutrition, using standardized nutrition screening tools. Becky Dorner, RDN, LD, FAND Becky Dorner & Associates, Inc. 2 3 4 Learn how malnutrition increases the risk for pressure ulcer development and interferes with wound healing. Learn what the latest research and the NPUAP guidelines have to say about the role of nutrition in pressure ulcer prevention and treatment. Learn practical nutrition and hydration solutions for the prevention and treatment of pressure ulcers - including the role of oral nutrition supplements and the amino acids arginine and glutamine. Definitions: Adult Malnutrition Malnutrition is most simply defined as any nutritional imbalance. (Dorland 2011) Undernutrition: lack of calories, protein or other nutrients needed for tissue maintenance and repair. Undernutrition and malnutrition used interchangeably. White J, J Acad Nutr Diet 2012:112:730-730 Adult Malnutrition Increases morbidity and mortality. Decreases function and quality of life. Increases frequency and length of hospital stay. Increases health care costs. White, 2012 J Acad Nutr Diet. 2012 112(5): 730-738. 3 4 UWL, undernutrition, PEM and dehydration are known risk factors for pressure ulcer development Pinchofsky; Lyder 2001; Dimant 1999; CMS F314 2004 Etiology-Based Malnutrition Definitions Low BMI, reduced food intake and impaired ability to eat independently are also risk factors Horn 2004; CMS 2008; Gilmore et al, 1995 Fry noted malnutrition and /or weight loss correlated with a 4 fold higher risk of the development of pressure ulcers (Fry 2010 ) Need to quickly identify and treat undernutrition especially when pressure ulcers are present. (Thomas, 2007) 5 6 2015 Becky Dorner & Associates, Inc. 1
Clinical Signs of Inflammation Laboratory Signs of Inflammation Abscess Fever Hypothermia Pneumonia Sepsis or bacteremia Urinary tract infection Wound or incision infection Decreased serum albumin serum transferrin serum prealbumin platelet count OR increased white blood cell count Increased C-reactive protein ( d in liver failure) blood glucose percentage of neutrophils in the CBC Marked negative nitrogen balance 7 Acute Disease/Injury: Indicators of Severe Inflammatory Response Chronic Disease: Indicators of Mild to Moderate Inflammatory Response Adult respiratory distress syndrome Closed head injury Critical illness Major abdominal surgery Major infection or sepsis Multi-trauma Systemic inflammatory response syndrome Severe burns Severe acute pancreatitis Cardiovascular disease Celiac disease Chronic pancreatitis Chronic obstructive pulmonary disease Congestive heart failure Cystic fibrosis Dementia Diabetes mellitus Inflammatory bowel disease Hematologic malignancies Metabolic syndrome Neuromuscular disease Obesity Organ failure/transplant (kidney, liver, heart, lung or gut) Pressure ulcers Rheumatoid arthritis Solid tumors Jensen G. A.S.P.E.N. Adult Core Curriculum, 3 rd ed 2012 9 Jensen G. A.S.P.E.N. Adult Core Curriculum, 3 rd ed 2012 10 Diagnosing Malnutrition: 2009 Academy Workgroup (with ASPEN reps.) Identification of >2 of the following characteristics: 1. Insufficient energy intake 2. Weight loss 3. Loss of muscle mass 4. Loss of subcutaneous fat 5. Localized or generalized fluid accumulation that may sometimes mask weight loss 6. Diminished functional status as measured by hand grip strength White J, J Acad Nutr Diet 2012:112:730-730 11 Characteristics of Non-Severe Malnutrition Characteristic Acute Illness/Injury Chronic Illness Social/Environmental 1. Insufficient Energy Intake 33-35 2. Interpretation of Weight Loss 15-16,36-37 3. Changes in Body Composition: Loss of Body Fat 13-14,34-35 4. Changes in Body Composition: Loss of Muscle Mass 15-16,36-37 5. Changes in Body Composition: Accumulation of Fluid 15-16,36-37 < 75% for > 7 days < 75% for > or = to 1 month 1-2%/1 week 5%/1 month 7.5%/3 months 5%/1 month 7.5%/3 months 10%/6 months 20%/ 1 year < 75% for > or = to 3 months 5%/1 month 7.5%/3 months 10%/6 months 20%/ 1 year Mild depletion Mild depletion Mild depletion Mild depletion Mild depletion Mild depletion Mild Mild Mild 6. Grip Strength 40-44 Not Applicable Not Applicable Not Applicable (Adapted from White, J. J Acad Nutr Diet 2012, 112.5. 730-738) 12 2015 Becky Dorner & Associates, Inc. 2
MST MNA MUST SNAQ Is Adult Malnutrition a Precursor to Pressure Ulcers? Characteristics of Severe Malnutrition Malnutrition and Pressure Ulcers Characteristic Acute Illness/Injury Chronic Illness Social/Environmental 1. Insufficient Energy < or = to 50% for > 5 < or = to 75% for > or < or = to 50% for 1 month Intake 31-33 days = to 1 month 2. Interpretation of Weight Loss 15-16,36-37 3. Changes in Body Composition: Loss of Body Fat 15-16,36-37 4. Changes in Body Composition: Loss of Muscle Mass 15-16,36-37 5. Changes in Body Composition: Accumulation of Fluid 15-16,36-37 >1-2%/1 week >5%/1 month >7.5%/3 months >5%/1 month >7.5%/3 months >10%/6 months >20%/ 1 year >5%/1 month >7.5%/3 months >10%/6 months >20%/ 1 year Moderate depletion Severe depletion Severe depletion Moderate depletion Severe depletion Severe depletion Moderate to Severe Severe Severe 6. Grip Strength 40-44 Markedly reduced Markedly reduced Markedly reduced (Adapted from White, J. J Acad Nutr Diet 2012, 112.5. 730-738) 13 Lyder Banks Iizaka U.S.: Medicare adults 65 at risk of pressure ulcers: 76% were malnourished (2001) Australia: Odds ratio of having a pressure ulcer are higher with malnutrition in acute and LTC (2010) Japan: Home care study: 65, rate of malnutrition 58.7% with pressure ulcers compared to 32.6% without them (2010) 14 Nutritional interventions should be included in every pressure ulcer prevention or treatment plan Nutrition Screening (Guidelines) Goals: Improve quality of life Stabilize or reverse UWL and malnutrition; restore nutritional status Prevent/heal pressure ulcers Treat nutrition problems: Adequate calories and protein (+ fluids, vits/min) Least restrictive diets to optimize food/fluid intake 15 1. Screen nutritional status for each individual at risk of or with a pressure ulcer: at admission to a health care setting; with each significant change of clinical condition; and/or when progress toward pressure ulcer closure is not observed. (Strength of Evidence = C, Strength of Recommendation -SOR = probably do it) Nutrition Screening (Guidelines) 2. Use a valid and reliable nutrition screening tool to determine nutritional risk. (Strength of Evidence = C, SOR = Probably do it) 3. Refer individuals screened to be at risk of malnutrition and individuals with an existing pressure ulcer to a registered dietitian or an interprofessional nutrition team for a comprehensive nutrition assessment. (Strength of Evidence = C; SOR = probably do it.) Malnutrition Screening Tool Valid and reliable for use in acute care and ambulatory care to identify malnutrition (Ferguson, M et al. Nutrition1999 15:458-464.) Validated Screening Tools Mini- Nutritional Assessment Validated in individuals with PUs Validated and easy to use in older adults in community and LTC (Paudla 2012) www.mnaelderly.com/ Malnutrition Universal Screening Tool To identify risk of undernutrition (BAPEN, 2008) Validated for use in older adults admitted to acute care http://www.ba pen.org.uk/mu st_tool.html Short Nutrition Assessment Questionnaire Acute care, residential care and community adults >65. http://www.fi ghtmalnutriti on.eu/fightmalnutrition/ screeningtools/snaqtools-inenglish/ 18 2015 Becky Dorner & Associates, Inc. 3
Referrals Medical Nutrition Therapy Refer to RDN, IDT, others as needed based on nutrition screening results Be sure systems are in place for referrals (EMR set up to trigger RDN referral) Comprehensive nutrition assessment forms the basis for all nutrition interventions Early intervention is critical Nutritional interventions should be included in every pressure ulcer prevention or treatment plan. Goals: Pressure ulcer prevention Treatment to promote healing and restore nutritional status Nutrition Assessment for Pressure Ulcers (Guidelines) 1. Assess weight status of each individual to determine weight history and identify significant weight loss (>5% change in 30 days or >10% in 180 days). (SOE = C, SOR = Probably do it) 2. Assess the individual s ability to eat independently. (SOE = C, SOR = Definitely do it) 3. Assess the adequacy of total nutrient intake (food, fluid, oral supplements, enteral/parenteral feedings). (SOE = C, SOR = Definitely do it) Nutrition Focused Physical Assessment Weight loss, muscle wasting, loss of subcutaneous fat, fluid accumulation, and diminished functional status - all important indicators of malnutrition Review: Overall energy, strength, endurance Ability to perform ADLs Hand-grip strength Examine: Eyes, mouth, skin, nails, hair and extremities, overall appearance (robust, normal, underweight or cachectic) Oral: Dental condition, sore mouth, inflamed, swollen or bleeding gums Skin: pressure ulcers, skin tears, bruises, turgor, dryness Assess for edema 22 What about Lab Values? Serum protein levels: May be affected by inflammation, renal function, hydration and other factors Do not specifically indicate malnutrition, accurately measure nutritional repletion, or respond to nutrition interventions during the active inflammatory response May reflect severity of the inflammatory process May be useful to help establish overall prognosis by indicating morbidity, mortality and severity of illness Important to: Assess for anemia Assess for dehydration Monitor blood glucose levels Ferguson 1993, White 2012, Covinski 2002, Furhman 2004, Shenkin 2006, Myron Johnson, 2007 Care Planning (Guidelines) 1. Develop an individualized nutrition care plan for individuals with or at risk of a pressure ulcer. (SOE = C, SOR= Probably do it) RDN in consultation with IDT should develop/document an individualized nutrition intervention plan based on nutritional needs, feeding route and goals of care. 2015 Becky Dorner & Associates, Inc. 4
Care Planning (Guidelines) General Recommendations 2. Follow relevant and evidencebased guidelines on nutrition and hydration for individuals who exhibit nutritional risk and who are at risk of pressure ulcers or have an existing pressure ulcer. ( SOE = C, SOR = Probably do it) Dining Service Director CNA, feeding assistants Physician Patient: focus of care Nursing staff Nutrition is an interprofessional issue and nutrition interventions Allen 2013 should be included in every pressure ulcer prevention or treatment plan. RDN, DTR SLP/OT Use your clinical judgment based on a thorough medical and nutritional assessment to make appropriate individualized recommendations. Individualized care plan should focus on: improving and/or maintaining overall nutritional status acceptance of nutrition interventions positive clinical outcomes Energy Intake (Guidelines) 1. Provide individualized energy intake based on underlying medical condition and level of activity. (SOE = B, Probably do it) 2. Provide 30 to 35 kcalories/kg body weight for adults at risk of a pressure ulcer who are assessed as being at risk of malnutrition. (SOE = C, SOR= Probably do it) 3. Provide 30 to 35 kcalories/kg body weight for adults with a pressure ulcer who are assessed as being at risk of malnutrition. (SOE = C, SOR= Definably do it) Energy Intake (Guidelines) 4. Adjust energy intake based on weight change or level of obesity. Adults who are underweight or who have had significant unintended weight loss may need additional energy intake. (SOE = C, SOR= Definitely do it) 5. Revise and modify/liberalize dietary restrictions when limitations result in decreased food and fluid intake. These adjustments should be made in consultation with a medical professional and managed by a registered dietitian whenever possible. (SOE = C, SOR= Probably do it) Energy Intake (Guidelines) Helping Individuals Meet Energy Needs 6. Offer fortified foods and/or high calorie, high protein oral nutritional supplements between meals if nutritional requirements cannot be achieved by dietary intake. (SOE = B, SOR= Definitely do it) 7. Consider nutritional support (enteral or parenteral nutrition) when oral intake is inadequate. This must be consistent with the individual s goals. (Strength of Evidence = C, SOR= Probably do it) Real food first! Favorite foods, individualize diet, dining interventions Medication adjustments (Interactions: anorexia, nausea, GI concerns, etc.) Social/ psychological interventions Supplements, enhanced foods, and food fortifiers help combat UWL and malnutrition 2015 Becky Dorner & Associates, Inc. 5
Calorie Boosters from Your Kitchen Margarine, butter, mayonnaise or peanut butter added to appropriate foods Whole milk or cream in pudding, soups, hot cereals, hot cocoa (in place of water) Cheese Fried foods Ice cream Honey or maple syrup Milkshakes High calorie/protein beverages, bars 31 1. Provide adequate protein for positive nitrogen balance for adults assessed to be at risk of a pressure ulcer. (SOE = C, SOR = Probably do it) 2. Offer 1.25 to 1.5 grams protein/kg body weight daily for an adult at risk of a pressure ulcer who is assessed to be at risk of malnutrition when compatible with goals of care, and reassess as condition changes. (Strength of Evidence = C, SOR = Probably do it) 3. Provide adequate protein for positive nitrogen balance for an adult with a pressure ulcer. (Strength of Evidence = B, Probably do it) 4. Offer 1.25 to 1.5 grams protein/kg body weight daily for adults with an existing pressure ulcer who is assessed to be at risk of malnutrition when compatible with goals of care, and reassess as condition changes. (SOE = C, SOR = Probably do it) 5. Offer high calorie, high protein nutritional supplements in addition to the usual diet to adults with nutritional risk and pressure ulcer risk, if nutritional requirements cannot be achieved by dietary intake. (SOE = A, SOR = Probably do it) Protein Boosters from Your Kitchen 6. Assess renal function to ensure that high levels of protein are appropriate for the individual. (SOE = C, SOR = Definitely do it) Clinical judgment is required to determine the appropriate level of protein for each individual, based on the number of pressure ulcers present, overall nutritional status, co-morbidities, and tolerance to nutritional interventions. Meat, poultry, fish, as tolerated Cheese or cheese sauce added to vegetables, casseroles, soups Eggs: scrambled, omelet, etc. Full fat cottage cheese, yogurt Double strength milk or milk or protein powder added to soups, hot cereals, pudding, mashed potatoes, etc. Whole milk or cream in soups, cereals, hot cocoa (in place of water) 36 2015 Becky Dorner & Associates, Inc. 6
Oral Nutritional Supplements Significantly fewer hospital readmissions with high pro ONS High protein ONS increased total dietary intake and improved body weight ONS use is associated with decreased length of stay, episode cost, and 30-day readmission risk (ROI of $2.56 net savings due to averted 30-day readmissions for every $1.00 spent on ONS in the matched sample) 1. Cawood AL, Elia M, Stratton RJ. Systematic review and meta-analysis of the effects of high protein oral nutritional supplements. Ageing Research Reviews, Volume 11, Issue 2, April 2012, Pages 278 296. Accessed 8/22/13 at http://www.sciencedirect.com/science/article/pii/s1568163711000900. 2. Jensen GL. Oral nutritional supplementation. Am J Manag Care. 2013:19:119-120. Accessed 8-22-13 http://www.ajmc.com/publications/issue/2013/2013-1-vol19- n2/oral-nutritional-supplementation. 37 7. Supplement with high protein, arginine and micronutrients for individuals with a pressure ulcer Category/Stage III or IV or multiple pressure ulcers when nutritional requirements cannot be met with traditional high calorie and protein supplements. (SOE = B, SOR = Probably do it) NEW! Hydration (Guidelines) Hydration (Guidelines) 1. Provide and encourage adequate daily fluid intake for hydration for an individual assessed to be at risk of or with a pressure ulcer. This must be consistent with the individual s comorbid conditions and goals. (SOE = C, SOR = Definitely do it) 2. Monitor individuals for S/S dehydration: changes in weight, skin turgor, urine output, elevated serum sodium and/or calculated serum osmolality. (SOE = C, SOR = probably do it) 3. Provide additional fluid for individuals with dehydration, elevated temp, vomiting, profuse sweating, diarrhea or heavily draining wounds. (SOE = C, SOR = Definitely do it) 40 Methods of Calculating Fluid Needs Helping Individuals Meet Fluid Needs 1 ml/calorie consumed 30 ml/kg BW/day In generally healthy individuals that are adequately hydrated, food accounts for >20% of total fluid intake (DRI 2004) Total fluid needs include water content of food 1 Offer sips at every interpersonal contact 2 Encourage favorite fluids between meals (including pudding, ice cream, sherbet) 3 Extra fluids at med pass 2015 Becky Dorner & Associates, Inc. 7
Vitamins and Minerals (Guidelines) 1. Provide/encourage individuals assessed to be at risk of pressure ulcers to consume a balanced diet that includes good sources of vitamins and minerals. (SOE = C, SOR = Definitely do it) 2. Provide/encourage an individual assessed to be at risk of a pressure ulcer to take vitamin and mineral supplements when dietary intake is poor or deficiencies are confirmed or suspected. (SOE = C, SOR = Probably do it) Vitamins and Minerals (Guidelines) 3. Provide/encourage an individual with a pressure ulcers to consume a balanced diet that includes good sources of vitamins and minerals. (SOE = B, SOR = Definitely do it) 4. Provide/encourage an individual with a pressure ulcer to take vitamin and mineral supplements when dietary intake is poor or deficiencies are confirmed or suspected. (SOE = B, SOR= Probably do it) Vitamin C Zinc Involved in the synthesis of collagen Acts on fibroblast proliferation and cellular immunity There is no support for vitamin C above the DRI unless a deficiency is diagnosed or suspected. 2015 BDA and MEP Zinc: contributes to protein and DNA synthesis; immune function and cellular proliferation Zinc requirements can be met by 2 servings/ day of animal protein. No research has demonstrated an effect of zinc supplementation on improved pressure ulcer healing. A multivitamin/ mineral supplement daily (15 mg zinc) may be adequate. (DRI 2004) Obesity There are no evidence based guidelines available related to the nutritional needs of the obese person with pressure ulcers. Adequate calories, protein, fluids and nutrients are needed for healing. General consensus is that diets should be liberalized to promote healing. Once the pressure ulcer is completely healed, diet restrictions may be gradually implemented as needed. Monitor skin integrity and coordinate with RDN (ongoing). 2014 NPUAP Unavoidable Pressure Injury State of the Science Consensus Conference Individuals with malnutrition in combination with multiple comorbidities are at increased risk for the development of unavoidable pressure ulcers. 91% Individuals with cachexia are at increased risk for the development of unavoidable pressure ulcers. 100% 47 2015 Becky Dorner & Associates, Inc. 8
Implications for Practice Case Study: Betty Poor health outcomes may be associated with UWL and malnutrition. Refer to the RDN as soon as risk of/confirmation of malnutrition or pressure ulcer is identified. Early nutrition interventions can prevent and/or delay malnutrition and hydration deficits and their impact on pressure ulcer development and/or healing. 49 Focus the individual care plan on improving overall nutrition status through accepted nutrition interventions to create positive outcomes Most Important The Role of Nutrition for Pressure Ulcer Management: National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, and Pan Pacific Pressure Injury Alliance White Paper http://journals.lww.com/aswcjou rnal/fulltext/2015/04000/the_r ole_of_nutrition_for_pressure_ Ulcer.7.aspx Mary Ellen Posthauer, RDN, LD, CD, FAND, Evansville, IN Merrilyn Banks, PhD, Herston, Queensland, Australia Becky Dorner, RDN, LD, FAND, Naples, FL Jos M.G.A. Schols, MD, PhD, Maastricht, The Netherlands April 20015, Advances in Skin and Wound Care The Journal for Prevention and Healing 2015 Becky Dorner & Associates, Inc. 9