Identifying those at risk

Malnutrition is a growing issue in the rehabilitation setting, writes Michelle Miller, Elisabeth Isenring and Angela Vivanti.

High rates of nutritional risk have long been documented in acute care settings and, more recently, across rehabilitation settings. People are commonly admitted to inpatient or ambulatory rehabilitation services following an acute hospital stay, where nutritional health may have declined. 

Malnutrition often goes unrecognised and untreated and can be associated with negative health outcomes. Poor nutritional status results in fatigue, infection, delayed wound healing, an increased burden to nursing staff, increased length of stay and the inability to return to pre-morbid levels of independence.

Recent figures estimate that between 30 to 50 per cent of those in rehabilitation settings are malnourished. These figures likely worsen when physical therapy regimes are implemented in rehabilitation, without attention given to the increased nutrition support required for the increased activity and tissue repair.

Rehabilitation nurses are critical patient advocates and play a key role in identifying nutritional risk – and preventing nutritional decline. But with dozens of nutrition screening tools available it can be confusing for decision makers to choose one for routine use and to be confident that this is identifying appropriate people for targeted dietary intervention.

Nutrition screening
The Evidence Based Practice Guidelines for the Nutritional Management of Malnutrition in Adult Patients Across the Continuum of Care, published in 2009 by the Dietitians Association of Australia, assists with such decision making. According to these guidelines, the Mini-Nutritional Assessment – Short Form and Rapid Screen tools are currently the two most appropriate nutrition screening tools for use in the rehabilitation setting.

Mini-Nutritional Assessment – Short Form
Developed specifically for older adults, this tool consists of six items covering mobility, presence of disease/illness, neuropsychological status, appetite, weight change and body mass index. The generated score advises the level of risk and the need to refer for further assessment to an accredited practising dietitian (APD).

Rapid Screen
This tool consists of two items – weight change and body mass index. Similar to the Mini-Nutritional Assessment – Short Form, a score is generated and the need for referral for further assessment is established.

Dietary strategies for nurses in rehabilitation settings
Identifying those at nutritional risk using one of the above tools is only the first step. Timely dietary intervention strategies must be started, where appropriate by rehabilitation nurses or, in some instances, by referring to an APD.

Some simple dietary strategies that can be initiated by rehabilitation nurses include:

Ensuring foods are accessible to all. Some questions to ask include: Is the meal time protected from interruption? Can meals be reached by the patient? Is help offered if needed to open packaging? Can the person manage cutlery? Is the food texture appropriate? Is the meal environment conducive to eating? In the ambulatory setting, does the patient have support for shopping and meal preparation (such as Meals on Wheels or family support)?

Encouraging patients to consume nutrient-dense foods at meal times. These are foods that are high in energy and protein, such as meat, eggs and protein-rich vegetarian options (such as legumes).

Encouraging patients to order or purchase nutrient-dense snacks (such as milkshakes and/or oral sip feeds).

Ensuring staff meal breaks are always before or after the patient meal time. This is a simple, effective way to help make sure staff are available to provide individualized care.

Weighing patients on admission and at regular intervals. This also helps to provide documentation that adequate nutritional support is being provided.

The role of accredited practising dietitians
Some rehabilitation settings employ one or more APDs to provide medical nutrition therapy for malnourished people. This involves a comprehensive nutritional assessment, combined with an individualised nutrition care plan. The APD will provide education and counselling to the patient, family or carers, and rehabilitation staff. An APD may also:

• Establish specific menus
• Advise on appropriate foods, fluids and snacks for between meals
• Upskill food service and other staff on recognising and communicating inadequate ordering or food consumption by patients.

To find an APD, go to www.daa.asn.au and click on the ‘Find an APD’ tab or call the toll free APD hotline on 1800 812 942 and ask for the contact details of local APDs. Patients may be eligible for a rebate through Medicare if they are under a care plan for a chronic condition that is being coordinated by a GP. Frail older adults may be eligible for dietetic services through HACC.

Monitoring and review: Key ingredients in tackling malnutrition
Regular monitoring and review of rehabilitation patients is important as circumstances can alter rapidly in this setting. Malnutrition and unintentional weight loss are frequently overlooked, especially in those who may appear to be of normal weight or overweight.

Systems for identifying new cases of nutritional risk or malnutrition are imperative. This can be as simple as introducing a policy for weekly nutrition screening of all rehabilitation patients. And systems need to make sure positive screening results are acted upon. In most settings, this can be achieved establishing a quarterly audit.

There is an emerging interest in the role nutrition can play in patient outcomes in the rehabilitation setting. Rehabilitation nurses are in a position to work with APDs to provide evidence-based nutritional care and to therefore help improve outcomes for both patients and health care services.

Michelle Miller PhD APD, Liz Isenring PhD AdvAPD and Angela Vivanti PhD AdvAPD, were members of the Dietitians Association of Australia’s Malnutrition Guideline Steering Committee, which produced Evidence Based Practice Guidelines for the Nutritional Management of Malnutrition in Adult Patients Across the Continuum of Care.

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