40% patients are known to be malnourished on admission to hospitals in Australia. According to Australian Dietetics Association this increases to 70% in residents in Residential Aged Care Facilities (RACF). Malnutrition is clinically suspected in patients with a BMI < 18.5 and unintentional weight loss > 5% body weight.
Malnutrition is screened on admission to many Australian hospitals using the Malnutrition Screening Tool (MST) a simple three question tool designed for use by non-dietetic staff. Patients are referred to Dietetics if they have a score >2 for assessment, review and implementation of a nutrition management plan. Overweight and obese patients are similarly at risk for malnutrition and benefit from dietetic intervention particularly during times of illness and surgery.
General causes contributing to malnutrition are related to
- inadequate oral intake (NIL by mouth peri-operatively, nausea\vomiting)
- increased nutritional requirements (wound healing, pressure injuries)
- impaired absorption
- altered transport
- altered nutrient utilisation
Malnutrition increases morbidity and mortality. Additionally malnutrition impairs functional recovery, increases muscle loss, impairs wound healing, increases the risk for infection and complications, increases length of stays (LOS), affects quality of life and increases financial cost for hospitals and organisations. Significant oedema associated with decreased albumin blood levels impacts negatively on mobility and functional recovery. Hypoalbuminemia is also a predictor for morbidity more frequently cardiovascular morbidity, infection and organ dysfunction.
Albumin is a negative acute-phase protein which plays a major role in fighting infections, building and repairing muscle tissue. If the body is not taking in enough dietary protein the liver is less able to make new albumin further decreasing albumin levels. Normal range of albumin in blood is 3.5-5.5 g\l. Maintaining levels of serum albumin within the normal range prevents the development of tissue oedema through maintenance of the colloid osmotic plasma pressure. The rate of loss of albumin to the tissue spaces (transcapillary escape rate) increases significantly when infection and sepsis if present.
A number of the more complex protocols that have been developed to detect malnutrition in adults rely on changes in acute phase proteins such as serum albumin and prealbumin as primary diagnostic indicators of adult malnutrition.
Monitoring albumin levels has been advocated as a prognostic tool to identify higher-risk patients because of the strength of the association and low cost of serum albumin assays. The acute-phase proteins—in particular C-reactive protein (CRP) may help identify the risk of infection or sepsis. Strong correlation between serum albumin and CRP with has been reported.
Studies suggest that administering sufﬁcient exogenous albumin to achieve serum albumin level of more than 3.0 g/L lessens morbidity in hypoalbuminemia patients. Parenteral albumin solutions (200 or 300 mls of 20% albumin) have a good safety record. The ALBIOS study protocol stipulated that albumin administration should be titrated to maintain serum albumin > 3.0 g|l with albumin levels being measured on a daily basis.
Individual factors contributing to malnutrition
- Limited mobility
- Inability to chew or swallow
- Sensory loss (taste, smell)
- Lack of adequate intake
- Treatment (ventilation, surgery, drain tubes)
- Drug therapy
- Inability to buy, cook or consume food
Organisational factors contributing to malnutrition
- Failure to recognise malnutrition
- Lack of nutritional screening or assessment disease (e.g., cancer, diabetes, cardiac, gastrointestinal)
- Lack of nutritional training
- Confusion regarding nutritional responsibility
- Failure to record height and weight
- Failure to record patient intake
- Lack of staff to assist with feeding
- Importance of nutrition unrecognised
Malnutrition and hypoalbuminemia corrective strategies include the screening of all patients on admission to hospitals for malnutrition with a full nutritional assessment for patients identified at risk. Prescribing of oral supplemental high protein high energy drinks and frequent small meals of choice should form part of a nutritional management plan. Integration of new practises such as protected meal times provides the opportunity for staff to facilitate and monitor oral intake.
Regular blood analysis and review is recommended for patients considered high risk. Studies suggest that for post-operative patients an increased CRP level day 3 post op is a strong predictor for hypoalbuminemia on day 7.
Malnutrition and hypoalbuminemia continues to be unrecognised as such contributing factor in clinical deterioration of patients. Further awareness and education is needed for both nurses and medical staff if prevalence rates are to improve.