Quality Indicators for Malnutrition for Vulnerable Community

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Quality Indicators for Malnutrition for Vulnerable Community

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Quality Indicators for Malnutrition for Vulnerable CommunityDwelling and Hospitalized Older Persons
WR-182 August 2004

David Reuben, MD From the Division of Geriatrics, University of California, Los Angeles
This study was supported by a contract from Pfizer Inc to RAND.
Corresponding author is Dr. Reuben at UCLA, UCLA Division of Geriatrics 10945 Le Conte Ave., Suite #2339 Los Angeles, CA 90095-1687
Word Count: 3983 Number of Tables: 2

As a population, older adults are more likely than younger ones to be afflicted with a variety of age-related diseases and functional impairments that may interfere with the maintenance of good nutritional status. This is particularly true of “vulnerable elders”, defined as individuals age 65 and older who are at increased risk for functional decline and death. This population is also at increased risk of drug-induced nutritional deficiencies due to the number of prescription drugs they take. As a result of these potential risks for malnutrition, the Department of Health and Human Services’ health goals for the nation, Healthy People 2000,(1) has identified nutrition as a priority area. In addition, the American Academy of Family Physicians, the American Dietetic Association and the National Council on the Aging, Inc. have created the Nutrition Screening Initiative (NSI) to promote nutrition screening and better nutritional care of older persons.(2)
The term “malnutrition” can encompass a wide range of deficiencies (e.g., protein-energy, vitamins, fiber, water) and excesses (e.g., obesity, hypervitaminosis), which may or may not be clearly associated with adverse health outcomes.(3) Among these, undernutrition has emerged as a priority area in caring for older persons. For example, an expert panel recently ranked undernutrition as third leading condition in hospital and home care sites and the fourth leading condition in office practice and nursing home sites for which quality improvement efforts would enhance the functional health of older persons.(4) Accordingly, the potential quality indicators (QIs) presented in this paper focus specifically on energy undernutrition, as well as on obesity. This paper does not address vitamin, mineral, fiber, or water disturbances.
Developing quality indicators for malnutrition in older persons is problematic because there is no universally accepted clinical definition of malnutrition(5) and because the amount of research conducted on malnutrition in older persons, though voluminous, has not systemically focused on issues of quality of care. As a result, there are substantial knowledge gaps in the literature, and most of the proposed quality indicators in this paper are not supported by randomized clinical trials. When clinical trials have been

available, almost all have been small and many have studied patients who met narrow entry criteria. Moreover, many of the trials do not meet the highest quality of methodological rigor (e.g., concealed randomization and complete follow-up). Thus, even the clinical trial evidence cannot be regarded as conclusive when evaluating the proposed quality indicators in this paper.
The methods for developing these quality indicators, including literature review and expert panel consideration, are detailed in a preceding paper.(6) For malnutrition, the literature search began with the author’s own extensive files from a prior review on the subject.(3) and the structured literature review identified 3,753 additional titles, from which abstracts and articles were identified that were relevant to this report. Based on the literature and the authors’ expertise, 17 potential quality indicators were proposed.
Of these, three potential quality indicators dealt exclusively with elders in nursing homes and are not reported here. Six potential indicators applied to hospitalized patients and eight potential indicators applied to community-dwelling patients. These 14 indicators are considered here.
Of the 14 potential quality indicators, eight were judged valid by the expert panel process (see Quality Indicator table) and 6 were not accepted The literature summaries that support each of the indicators judged to be valid by the expert panel process are described below.

Quality Indicator #1 Weight measurement ALL community-dwelling patients should be weighed at each physician office visit and these weights should be documented in the medical record BECAUSE this is an inexpensive method to screen for energy undernutrition and obesity that has prognostic importance.
Supporting evidence: There are no clinical trials supporting the routine measurement of weight having a positive effect on health outcomes. However, weight loss and low body mass index (BMI) have been associated with adverse outcomes in older persons and can be identified by routine measurement. In a 4-year cohort study, the annual incidence of involuntary weight loss (defined as loss of more than 4% of body weight) among community-dwelling veterans was 13.1%. Over a 2-year follow-up period, involuntary weight losers had an increased risk of mortality (RR = 2.4, 95% CI = 1.3 to 4.4), which was 28% among weight losers and 11% among those who did not lose weight. Voluntary weight losers had a 36% mortality rate during this time, suggesting that intentional weight loss may carry as poor a prognosis as unintentional weight loss in this population.(7) Two longitudinal studies also suggest that weight loss in later life predict mortality. In one, older persons who lost 10% of their body weight or more between ages 50 and 70 years had higher adjusted of mortality (men: RR = 1.69, 95% CI = 1.19 to 1.65; women: RR =1.62, 95% CI = 1.45 to 1.97).(8) In the other, women > 55 years of age who had an episode of unintentional weight loss had an adjusted odds ratio of 1.45 (95% CI 1.24, 1.70) for all-cause 5-year mortality.(9) However, the time span utilized in these latter definitions are impractical in clinical practice. Among Alzheimer’s patients followed for up to 6 years, > 5% weight loss in any year before death predicted mortality (relative risk 1.5, 95% CI 1.09, 2.07); 22% of Alzheimer’s patients experienced such weight loss.(10) Other definitions (e.g., 7.5% loss within 6 months) have been employed in small studies.(11) Among community-dwelling old persons, body mass index (BMI) demonstrates a "U" shaped relation with functional impairment, with increased risk among those at the lowest and highest BMIs.(12)

Data on the risks associated with obesity in older persons are less consistent. Several cohort studies have demonstrated that high BMI does not predict mortality, and that it may even be protective against early death in older persons.(13-15) However, other studies indicate that obesity predicts mortality even in the 75 years or older age group(16) and is related to the development of functional impairment.(12,17)
There have been few randomized clinical trials indicating that treatment of community-dwelling older persons who are at either extremes of BMI leads to improved clinical outcomes. The TONE study found that elderly overweight hypertensives who were assigned to either the weight loss or to the weight loss and reduced sodium intake arms of a randomized clinical trial improved their blood pressure control.(18) Epidemiological data from the Framingham cohort also indicated improvement in arthritis among obese patients who have lost weight.(19) In this study, a decrease in weight of approximately 5 kg in the preceding 10 years afforded a 50% reduction in the risk of symptomatic osteoarthritis.(7)
Quality Indicator #2 Document Weight Loss IF a vulnerable elder has involuntary loss of > 10% body weight over one year or less, THEN weight loss (or a related disorder) should be documented in the medical record as an indication that the physician recognized malnutrition as a potential problem BECAUSE some patients with weight loss have potentially reversible disorders.
Supporting evidence: To date, there have been no published randomized clinical trials that provide evidence for the reversibility of weight loss or improved outcomes as a result of interventions. Nevertheless, many of the causes of weight loss (e.g., depression, hyperthyroidism, gastrointestinal diseases, cancer)(11,20) are treatable with therapies that have been demonstrated to be effective in randomized clinical trials.

Quality Indicator #3 Evaluate Weight Loss and Hypoalbuminemia IF a community-dwelling vulnerable elder has documented involuntary weight loss or hypoalbuminemia (< 3.5 g/dL), THEN she or he should receive an evaluation for potentially reversible causes of poor nutritional intake BECAUSE there are many treatable contributors to malnutrition.
Supporting evidence: Many of the causes of weight loss (e.g., depression, hyperthyroidism, gastrointestinal diseases, cancer)(11,20) are treatable with therapies that have been demonstrated to be effective in randomized clinical trials. Serum albumin is the best-studied serum protein and has prognostic value for subsequent mortality and morbidity in community-dwelling older persons.(21-23) A recent study identified risk factors (Table 1), including some that may be reversible, for hypoalbuminemia among community-dwelling older persons.(24)
Table 2 lists medical and nutrition-related factors that may cause undernutrition. The linkages between correcting the potentially modifiable factors listed above, restoring serum albumin to normal values, and reducing the adverse sequelae associated with hypoalbuminemia have yet to be established. Oral health status has been associated weight loss, although trials have not demonstrated specific effects of treatment in this age group.(25,26) The optimal evaluation of weight loss or hypoalbuminemia in older persons has not been determined.
Quality Indicator #4 Evaluate Comorbid Conditions IF a community-dwelling vulnerable elder has documented involuntary weight loss or hypoalbuminemia (< 3.5 g/dL) THEN he or she should receive an evaluation for potentially relevant comorbid conditions including:

• medications that might be associated with decreased appetite (e.g., digoxin, fluoxetine, anticholinergics)
• depressive symptoms, and • cognitive impairment BECAUSE each of these represents a treatable contributor to malnutrition. Supporting evidence: There is no evidence from clinical trials that treatment of co-morbid conditions (other than depression) associated with weight loss and hypoalbuminemia leads to improved appetite, weight gain, and better patient outcomes. Nevertheless, many co-morbid conditions are treatable with therapies that have been demonstrated to be effective in clinical trials. Therefore, an indirect argument can be made that identifying and treating co-morbid conditions is important. Medication, depression, and cognitive impairment can all affect food intake, either directly or indirectly. Certain medication use (e.g., digoxin, antibiotics, selective serotinergic reuptake inhibitors) has been linked to decreased appetite;(27,28) therefore, discontinuing the offending agents would presumably lead to improved appetites. The treatment of depression in older persons has been demonstrated to improve quality of life and ameliorate symptoms, including weight loss. Although medication therapy of Alzheimer’s disease has not specifically been shown to improve appetite or weight, detection of dementia and implementation of adequate social support may help ensure that afflicted persons have food obtained and prepared for them, and fed to them as needed.(29)
Quality Indicator #5 Document Nutritional Status of Inpatient IF a vulnerable elder is hospitalized, THEN his or her nutritional status should be documented during the hospitalization by evaluation of oral intake or serum biochemical testing (e.g., albumin, prealbumin, or cholesterol) BECAUSE each of these measures has prognostic significance and can identify older

persons at risk of malnutrition or adverse outcomes (e.g., complications, prolonged length of stay, inhospital and up to one-year mortality).
Supporting evidence: Nutritional parameters, including intake and biochemical tests, have demonstrated predictive ability for adverse outcomes among hospitalized older persons. Yet there have been few data supporting the benefit of monitoring nutritional intake among hospitalized patients. However, a prospective observational study demonstrated that low caloric intake (< 30% of estimated need) during the first three days of hospitalization could predict in-hospital mortality independently of serum albumin, lymphocytopenia, and activity of daily living impairment upon admission.(30) A recent study identified poor nutrient intake (< 50% of calculated maintenance energy requirements) in 21% of hospitalized older persons.(31)
Nurses and aides routinely observe dietary intake and thus offer the potential for inexpensive detection of potential nutritional disorders among hospitalized older persons. In general, though, the methods for communicating poor dietary intake observed by nursing staff to physicians have been informal and haphazard. Whether formal calorie counts obtained by food records provide additional value beyond nurse and aide observations has not been established. One report documented that among hospitalized patients, a one-day calorie count corresponded very closely to the values obtained by a threeday calorie count for energy and protein intake.(32)
Although the relationship between serum albumin and nutritional intake is not well established, hypoalbuminemia is commonly considered a sign of malnutrition. In fact, low serum albumin levels may be a better measure of inflammation and associated decrease in albumin synthesis, increase in albumin degradation, and transcapillary leakage than of malnutrition. Nevertheless, several studies have associated low serum albumin in hospitalized older persons (measured at various times during the hospitalization) with in-hospital complications, longer hospital stays, more frequent re-admissions, inhospital mortality, and increased mortality at 90 days and at one year.(30,33-46) When considering mortality, the lower the albumin level, the higher the risk of death. Although the optimal threshold for

identifying an increased risk of mortality has not yet been established, it may be considerably higher than the traditional 3.5 g/dL cut-point used to define protein energy undernutrition.(47) Prealbumin has also been demonstrated to have long-term prognostic value for mortality for patients admitted to a geriatric assessment unit.(48)
Low or falling serum cholesterol has been explored as another nutritional marker. In a case control study of older persons with normal cholesterol levels on admission to the hospital (≥160 mg/dL), those whose cholesterol levels fell to ≤120 mg/dL during hospitalization had more infectious and noninfectious complications, and their length of stay was nearly three times as long as those who maintained normal cholesterol levels. Mortality rates were higher in the acquired hypocholesterolemia group, though not significantly so.(49) However, acquired hypocholesterolemia may not be nutritionally mediated. Recent reports support the hypotheses that ongoing inflammation and proinflammatory cytokines, particularly IL-6, may be responsible for acquired hypocholesterolemia.(50)
Quality Indicator # 6 Alternative Alimentation in Hospitalized Older Persons IF a hospitalized vulnerable elder is unable to take foods orally for more than 72 hours, THEN alternative alimentation (e.g., enteral or parenteral) should be offered BECAUSE such patients are at high risk of malnutrition that can improve with caloric supplementation.
Supporting evidence: Some, but not all, studies of hospitalized elderly persons support the reversibility of undernutrition. To date, there have been no evidence-based protocols for determining when alternative feeding methods should be employed in hospitalized older persons who are not eating. A meta-analysis indicated that hospitalized persons with malnutrition who were started on some type of nutritional intervention on the third hospital day or before had an average length of stay of 3.0 days less than those who were started on the fourth or later hospital day.(51) Decisions to initiate and continue
Weight LossPersonsMalnutritionMortalityTrials