What is the approach to physical assessment and management of a patient with protein calorie malnutrition in a hospice setting?

Physical Assessment and Management of Protein Calorie Malnutrition in Hospice Care

In hospice care, physical assessment of patients with protein calorie malnutrition (PCM) should focus on comfort and quality of life rather than aggressive nutritional repletion, with oral nutritional supplements offered only if they enhance comfort and are tolerated by the patient. 1

Initial Assessment Components

• Conduct systematic malnutrition screening using validated tools like the Mini Nutritional Assessment (MNA) short-form, which includes assessment of mobility and neuropsychological problems in addition to standard parameters 2

• Perform a general clinical assessment including:

  • History of unintentional weight loss (>10% within past 6 months or >20% beyond 6 months indicates severe PCM) 1
  • Physical examination for visible signs of muscle wasting (sarcopenia) 2, 1
  • Assessment of body composition and muscle mass/strength 2

• Evaluate for clinical manifestations of advanced PCM:

  • Sarcopenia (loss of muscle mass and strength) 1
  • Edema or ascites that may mask weight loss 1, 3
  • Decreased physical performance and functional capacity 1

Anthropometric and Functional Measurements

• Measure weight and height to calculate BMI, correcting for fluid retention when applicable 1, 3
• Assess handgrip strength as a functional measure of nutritional status 1
• Measure mid-upper arm circumference and derived midarm muscle circumference to evaluate muscle mass 3
• Document functional status using validated scales such as WHO or Karnofsky scale 1

Laboratory Assessment

• Complete blood count to assess anemia and total lymphocyte count (reflects protein status and immune function) 3, 4
• Serum proteins assessment including albumin and pre-albumin (noting these are also affected by inflammation) 2, 3
• Consider checking inflammatory markers like C-reactive protein to correctly interpret albumin levels 3
• Evaluate for common micronutrient deficiencies that accompany PCM:
  • Vitamins B12, folate, A, D, and iron studies 3, 4
  • Zinc and copper levels, particularly with symptoms like poor wound healing 3, 4

Dietary Intake Assessment

• Monitor dietary intake for several days (e.g., using plate diagrams) to estimate food and fluid consumed 2
• Compare actual intake to estimated requirements (at least 1.0 g/kg protein should be ensured in older persons) 2
• Assess for appetite loss, which has high prognostic power in predicting malnutrition risk 2

Management Approach in Hospice Setting

• Focus interventions on comfort and quality of life rather than aggressive nutritional repletion 1, 2
• Offer mealtime assistance for patients with eating dependency to support adequate intake for comfort 2
• Encourage sharing mealtimes with others to improve quality of life and stimulate intake when appropriate 2
• Consider oral nutritional supplements only if they enhance comfort and are tolerated 1
• In terminal patients, parenteral nutrition should only be given in accordance with other palliative treatments 1
• Address psychological needs through counseling and optimal pain control as part of comprehensive supportive care 2

Monitoring and Follow-up

• Regularly reassess nutritional status and adjust interventions according to the patient's changing condition 2
• Coordinate nutritional care with the interdisciplinary team (medical specialists, nurses, therapists) 2
• Maintain intensive communication with the patient and family regarding wishes and expectations throughout the process 2

Special Considerations

• In patients with liver disease, accurate estimation of nutritional status is complicated by fluid retention 1
• Weight loss should not be recommended in patients with decompensated end-stage liver disease 1
• Refeeding process may precipitate shortages of potassium, phosphate, and magnesium if not carefully monitored 4
• Ensure comprehensive assessment before determining PCM as the primary hospice diagnosis 1