Identifying nutrition and hydration issues

When nutrition and hydration issues are identified early, we can tailor care and treatment to respond to each patient’s biological and medical needs, abilities, and their lifestyle and cultural preferences.

In addition to following health service specific policy and procedures, the following actions can help identify patients who have or are at risk of problems.

Screen patients

Screen all patients over 65 years within 24 hours of hospital admission. We should consider those patients who require surgery, as routine fasting for prolonged periods can lead to serious complications in people who are malnourished.¹

Use a validated screening tools such as the following.

The Malnutrition Screening Tool (MST)

This simple three-step tool assesses recent weight and appetite loss and is the most widely used nutritional screening tool in Australian hospitals. It can be used by staff, family or friends. It asks two questions, gives a score to indicate risk of malnutrition, and recommends steps for follow-up².

The Mini Nutrition Assessment (MNA)

This assessment was developed for people over 65 years. It explores 18 items relating to the patient’s medical, lifestyle, dietary, anthropometrical and psychosocial factors². The score indicates patients at risk of or suffering from malnutrition.

The Mini Nutrition Assessment Short Form (MNA-SF)

This shorter version of the MNA includes a ‘two step nutrition screen’ that identifies patients with under-nutrition and patients who should be referred to a dietitian for further assessment. This form is useful for patients who are not suspected to be at risk of malnutrition.

The Malnutrition Universal Screening Tool (MUST)

This five-step screening tool is simple to use and can be used by all care workers. It focuses on Body Mass Index (BMI), unexplained weight loss and acute illness effect and can also be used to detect obesity. This tool provides management guidelines to assist with developing a care plan.³

Take a thorough patient history

A medical history should explore the following issues.

Medication

• What medications are being taken? Some can cause nausea or affect appetite.
• Be aware that if the patient is not eating and drinking well, they may not metabolise medications effectively.

Continence

• Incontinence and constipation can impact on nutrition. For example, patients who are constipated are at risk of developing delirium.
• Some patients may drink less in fear of using the toilet regularly.

Other conditions or impairments

• Arthritis or vision impairment can affect the person’s ability to open food packages and feed themselves.
• Pain and nausea may reduce appetite.
• Stroke and Parkinson’s disease can affect a person’s food consumption and ability to safely swallow and feed themselves.
• Cognitive impairment, such as dementia or delirium, can cause problems with eating and drinking, especially in an unfamiliar environment.
• Social isolation can impair a person’s ability to access adequate healthy food. For example, a change in home circumstances or lack of social or physical support can make it difficult for someone to get to shops.
• Lifestyle diseases, such as diabetes, hypertension, alcoholism and smoking, can impact on nutrition and vitamin absorption.

Be alert to signs of dehydration

Dehydration is very common in older patients, and if not addressed can lead to serious complications including prolonged recovery from illness and surgery, and increased mortality. Dehydration also increases the risk of serious medical complications such as delirium, urinary tract infections, medication toxicity, decreased muscle strength and falls.^4,5

Be aware of the signs of dehydration in patients who are malnourished as 70 per cent of our daily fluid requirements can be obtained from the diet.⁴ Signs of dehydration include:

• postural hypotension – dizziness from the sit to standing position
• decreased urinary output
• dark urine colour
• dryness of the mouth
• poor skin turgor
• sunken eyes^4,6
• headaches
• fatigue
• constipation.

Gather information from the patient and their family

Asking the patient (and their family and carers) what matters to them enables us to tailor treatments to suit them. Ask if they have:

• noticed any changes in weight
• noticed changes in appetite
• specific food preferences and intolerances
• lost teeth, have mouth sores, if their dentures fit poorly or they have problems with chewing and swallowing
• been depressed or have experienced other changes to their mental and cognitive health
• people and services that support them at home, such as Meals on Wheels or help getting to the shops.

Do a physical examination

To gauge an older patient’s nutritional health, assessment should include the following issues.

Weight and height

Calculating the patient’s BMI provides a baseline to monitor their weight throughout their stay. A BMI of around 27.5 generally indicates better outcomes for older people⁷.

Vitamin deficiencies

The following are signs of vitamin deficiencies.

• Dry lips and dry scaly skin can indicate poor hydration and nutrient deficiency.
• Swollen, bleeding gums or a sore red swollen tongue (glossitis) can indicate vitamin C and or Vitamin B deficiency or gum disease.
• Pale skin, breathlessness on exertion, fatigue and dizziness can indicate iron deficiency.
• Pressure injuries are common in older people with poor nutrition and can indicate a need to promptly increase vitamin C and protein.
• Regular respiratory infections, such as colds, flu or COPD can indicate a compromised immune system and nutrient deficiencies.
• Poor mobility and balance, being bed bound or unable to sit upright to eat and drink – assist the patient with positioning and refer to a physiotherapist or occupational therapist.

Laboratory data

Take blood tests and check for deficiencies such as iron (Fe), vitamin D, calcium, B vitamins and zinc. Vitamin D and calcium are important for bone health, vitamin D also helps protect the immune system, low B levels are associated with delirium and dementia and low zinc levels can affect sense of taste and reduce appetite.^8,9

Work with a dietitian

If you think a patient is malnourished or at risk of malnutrition or dehydration, refer to a dietitian and ask the medical team for a comprehensive assessment. The dietitian may prescribe a specialised diet or supplements.

1. Daniels, L., Good nutrition for good surgery: clinical and quality of life outcomes. Australian Prescriber, 2003. 26(6).

2. Barker, L., Gout, B, Crowe, T, Hospital malnutrition: prevalence, identification and impact on patients and the healthcare system. Int J Environ Res Public Health, 2011. 8(2): pp. 514-27.

3. Bapen UK, Malnutrition Universal Screening Tool, www.bapen.org.uk

4. Wotton, K., Crannitch, K, Munt, R, Prevalence, risk factors and strategies to prevent dehydration in older adults, Comtemporary Nurse, 2008. 31(1): p. 16.

5. Mentes, J.C, Oral hydration in older adults: greater awareness is needed in preventing, recognizing and treating dehydration. American Journal of Nursing, 2006. 106(6): p. 49.

6. Fortes, M.B., Owen, J.A, Raymond-Barker, P, Bishop, C, Elghenzai, S, Oliver, S.J, Walsh, N.P, Is this elderly patient dehydrated? Diagnostic accuracy of hydration assessment using physical signs, urine and saliva markers. JAMDA, 2015. 16(3).

7. Deakin University. Carrying extra weight could be healthier for older people. 2014; Media Release. Available from: http://www.deakin.edu.au/news/latest-media-releases/2014/carrying-extra-weight-could-be-healthier-for-older-people

8. Hobbins, N., Eat to cheat ageing. 2014: Citrus Press, Northbridge, NSW.

9. Aliani, M., Udenigwe, C, Girgih, A, Pownall, T, Bugera, J, Eskin, M, Zinc deficiency and taste perception in the elderly. Critical Reviews in Food Science and Nutrition, 2013. 53: p. 5.