A PRACTICAL APPROACH TO NUTRITIONAL ASSESSMENT

General considerations on History and PE

a high index of suspicion for nutritional problems is very important in patients
who have primary diagnosis associated with malnutrition, such as: chronic
alcoholism, disorders of cognition, chronic myocardial, renal, pulmonary
insufficiency, malabsorption syndromes and multiple medication use.
Common PE findings in severely malnourished patients:
Pressure ulcers or poorly healing wounds
Edema
Dehydration
Poor dental status.
PE findings that may provide clue to nutritional deficits:
Cheilosis
Poor dentition
Angular stomatitis
Glossitis
Weight loss - most important finding indicating the presence of malnutrition
-to be significant weight loss must be involuntary
-some consider weight loss to be significant if loss is >10% or more
in 6 mos, >7.5 or more in 3 months or 5% or more in 1 month

Significant malnutrition can be present on individuals who are not underweight

Evaluation of body composition with height as the reference point to determine
if the patient is underweight or has loss weight
In both males females the height decreases by 1cm after the age of 20.
Lean body mass decreases by 6% per decade after the age of 25. By the age of
70 the lean body mass has decreased an average of 5 kg for females and 12 kg
for males. Thus greater fat percentage in the elderly but a decline in the Total
body water.
Subscapular and suprailiac skinfolds are the best predictors of fat stores in
male while triceps skinfold and thigh measurements are for females.
It is recommended that persons over the age of 65 have BMI between 24 and 29.

PROTEIN ENERGY MALNUTRITION

- best described as metabolic response to stress such as injury or infection
- hormonal changes lead to development of anorexia despite the presence of
increased nutrient needs
- associated with the presence of hypoalbuminemia and decreased clearance
of drugs and toxins
- diagnosed by the presence of a serum albumin level < 3.0g/dL
- characterized by:
dry skin and dermatitis (flaky paint),
impaired immune responses
Malabsorption leading to viscious cycle of malnutrition
 Patients may also develop severe dehydration due to the decline on thirst drive
Zinc deficiencies are increased in patients with pressure ulcers and may
contribue to decreased rate of healing.
Folate deficiencies are limited to patients with malabsorption and older
alcoholics.
Vitamin B12 level should be measured in patient being evaluated for memory
loss
PEM has shown to be a significant predictor of increased morbidity and
mortality in older persons.