108

Part II Nutrition Assessment, Consequences, and Implications

the pathophysiology of sarcopenic obesity. Sarcopenia may be intensified by cachexia; nevertheless, these are distinct diseases (15-17).

Cachexia: This is severe wasting that goes along with disease states (eg, cancer) and is the clinical conse- quence of a chronic, systemic inflammatory response characterized by loss of skeletal muscle with or without loss of fat mass. Anorexia, insulin resistance, and increased muscle protein breakdown are associated with cachexia (18). The prominent clinical feature of cachexia is weight loss. Researchers have proposed that in other chronic disease states (eg, end-stage renal disease, chronic pulmonary disease, congestive heart failure, rheumatoid arthritis, and AIDS), the proximal cause of cachexia is significant cytokine production leading to the breakdown of body protein (19). As older adults continue to age, severe inflamma- tory metabolism initiated by disease or trauma affects immunity, hepatic protein metabolism, lean body mass homeostasis, and fluid compartment shifts. This obscures the clinician’s ability to evaluate nutritional status and monitor nutrition outcomes (20). The Academy of Nutrition and Dietetics acknowl- edged the severity of UWL in older adults with the development of Unintended Weight Loss in Older Adults Evidence-Based Nutrition Practice Guideline, published in 2009. The guideline defines evidence- based recommendations that guide food and nutrition decisions in the older adult. Expert registered dietitian nutritionists (RDNs) identified risk factors and recom- mended interventions based on medical conditions, needs, goals, and desires of the older adult. The guide- line supports 28 recommendations that include an asso- ciation between increased mortality and underweight (BMI less than 20 or current weight compared with usual or desired body weight) or unintended weight loss, such as 5% in 30 days (21). Based on guideline recommendations, the Academy has recommended that older adults who have had unintentional weight loss should have at least three medical nutrition therapy (MNT) visits. In 2013, the Unintended Weight Loss in Older Adults Toolkit was published; this is the gold standard companion to the Academy’s Evidence-Based UWL Practice Guidelines, containing MNT protocols and documentation forms that can be used to imple- ment the practice guidelines (22). The companion doc- uments focus on the Academy’s Nutrition Care Process (NCP).

Medical nutrition therapy for those with UWL should be determined with the older adult in accor- dance with self-determined choices, goals, and prefer- ences. If the individual is unable to make independent decisions, a discussion should be held with his or her responsible party. The RDN and nutrition and dietetics

technician, registered (NDTR), along with other members of the interdisciplinary team (IDT), have unique knowledge, skills, and abilities to maximize the outcome potential of the older adult. The role of the RDN is the provision of MNT. The RDN may assign this responsibility to the NDTR based on demonstrated competency (23).

UNINTENDED WEIGHT LOSS DEFINED The definition of UWL (also referred to in the literature as involuntary weight loss) is a decrease in body weight that is not planned or desired. The Centers for Medicare & Medicaid Services (CMS) defines UWL as weight loss of 5% in 30 days, 7.5% in 90 days, and 10% in 180 days (24). Insidious weight loss, as defined by CMS, is gradual UWL (weight loss over time) (24). UWL can be a significantly large amount of weight loss in a rapid period of time or slow and insidious (1 to 2 pounds monthly) over several months. The treatment for UWL is vital to ensure optimal outcomes for the older adult. The cornerstone for man- agement of UWL in nursing facilities and communi- ty-based settings is early recognition and timely treatment of reversible disorders (25). See Box 7.1 for causes of weight loss in the long-term care setting and Box 7.2 for guidance on assessing percentage of usual body weight.

NUTRITION SCREENING TOOLS Nutrition screening precedes the NCP and is often done in physician offices/clinics, at congregate meal sites, in the home care environment, and in indepen- dent or assisted-living facilities. Screening tools help to identify those older adults who will benefit from a nutrition assessment; screening can be conducted by trained individuals other than the RDN (ie, nurses, dietary staff, certified nursing assistants [CNAs], and admissions or social service personnel). (See Chapter 6 for more information about nutrition screening.) Commonly used screening criteria for UWL may include diagnosis of undernutrition/malnutrition, weight change in the last 3 months, BMI less than 18.5, appetite change in the last 3 months, problems with chewing and swallowing, presence of diarrhea, and the need for diet modification (26).

There are several screening tools available for use in the community and health care facilities, but only a few are validated. Figure 7.1 (see page 116) shows the Mini Nutritional Assessment (MNA), a stand-alone screening tool based on the full nutritional assessment. It consists of six questions and streamlines the screen- ing process (27). Figure 7.2 (see page 117) shows the Short Nutritional Assessment Questionnaire (SNAQ),