Makindo Medical Notes

Related Subjects: | Dementias

🥣 Malnutrition and weight loss in adults are common, complex, and often multifactorial — especially in frailty, dementia, and chronic disease. They require multidisciplinary discussion involving physicians, dietitians, speech and language therapists, nurses, and family members. Addressing nutritional decline improves wound healing, immunity, physical function, and quality of life — even when full weight recovery is not possible.

📊 Daily Reference Intakes for Adults

• Energy: 8,400 kJ / 2,000 kcal per day
• Total fat: <70 g (saturates <20 g)
• Carbohydrate: 260 g (sugars <90 g)
• Protein: 50 g
• Salt: <6 g

⚠️ Identifying Adults “At Risk” of Malnutrition

• BMI <18.5 kg/m²
• BMI <20 kg/m² with unintentional weight loss >5% in 3–6 months
• Unintentional weight loss >10% in 3–6 months regardless of BMI
• Recurrent infection, poor wound healing, muscle wasting, or lethargy
• Frailty, cognitive decline, or inability to self-feed independently

🩺 General Assessment (Multifactorial Approach)

• Oral and mechanical factors: Dentition, chewing, swallowing, oral thrush, mucositis
• Gastrointestinal symptoms: Nausea, pain, diarrhoea, constipation, malabsorption
• Medication review: Drugs that suppress appetite or alter taste (digoxin, SSRIs, opiates)
• Psychological and social factors: Depression, isolation, loss of interest, access to food
• Comorbidities: Cancer, COPD, chronic infection, renal or liver disease
• End-of-life or palliative context: Clarify whether the goal is comfort or recovery
• Substance misuse: Alcoholism and poor diet frequently coexist

🎯 Setting Treatment Goals

• Agree and document goals with the patient (and carers where appropriate).
• Goals should be realistic, person-centred, and measurable — e.g.:
• Target weight or BMI improvement over 3–6 months
• Weight maintenance when gain is undesirable (e.g. advanced frailty)
• Reduced rate of weight loss where stabilisation is unrealistic (e.g. cancer cachexia)
• Improvement in appetite, strength, or mobility
• Improved wound healing or recovery from infection
• Maintenance of dignity, comfort, and enjoyment in end-of-life feeding

🧮 Screening: The MUST Tool (Malnutrition Universal Screening Tool)

🥛 Management of Weight Loss and Malnutrition

• Record baseline weight and trajectory — look for sustained loss or plateau.
• Exclude reversible causes: poor appetite, depression, dysphagia, GI disease, alcohol misuse.
• Encourage oral intake as first-line:
• Provide familiar, palatable, energy-dense meals (full-fat dairy, fortified milk, butter, cream).
• Offer small, frequent meals and snacks rather than three large meals.
• Supervise and protect mealtimes; involve family and carers.
• Oral nutritional supplements (e.g. Ensure®, Fortisip®) may be added between meals.
• Treat oral thrush, dental issues, or swallowing difficulty promptly.
• Address depression (e.g. mirtazapine) and use short steroid courses (e.g. dexamethasone) only if palliative or refractory anorexia.
• If unable to swallow safely (enteral feeding):
• Nasogastric (NG) tube: Short-term option (up to 4–6 weeks). Monitor for aspiration and tube displacement.
• Percutaneous endoscopic gastrostomy (PEG): For longer-term feeding (>30 days). Requires MDT decision and patient consent. Benefits vs. burdens must be carefully weighed, especially in advanced dementia or end-of-life care.
• If gut function is lost (parenteral nutrition):
• Parenteral feeding (PN): High complication risk (sepsis, thrombosis, electrolyte disturbance). Use only when enteral feeding is not possible.
• Requires central venous access (e.g. PICC or Hickman line) and specialist input.
• Monitor electrolytes, fluid balance, and micronutrients closely.
• “At-risk feeding” at end of life: If patients are dying, the focus should be comfort — allowing sips or tastes of food and drink if desired, not aggressive feeding. Hydration and nutrition should never override dignity and comfort.

💡 Physiological Insight

• During illness, the liver prioritises acute phase protein production and gluconeogenesis → muscle catabolism and nitrogen loss.
• Malnutrition reduces albumin synthesis, immune competence, and wound healing capacity.
• Low BMI correlates with sarcopenia and frailty, increasing fall risk and mortality.
• Refeeding after prolonged starvation risks refeeding syndrome: check phosphate, magnesium, and potassium before initiating feeding.

🧠 Key Learning Points

• Always look for a treatable cause of reduced intake before escalating to artificial feeding.
• Assess capacity and consent — feeding decisions are ethical as much as clinical.
• Oral route first, enteral second, parenteral last is the safe hierarchy.
• Weight stabilisation or slower decline may be a valid success in chronic disease.
• Nutrition support is both a science and an act of care — it preserves function, dignity, and hope.

📚 References

• BAPEN MUST Tool
• NICE CG32: Nutrition Support for Adults (2022 update)
• BSG & ESPEN Guidelines on Enteral and Parenteral Nutrition (2021)
• British Geriatrics Society: Frailty and Nutrition Best Practice Guide (2022)