Nutrition 411: Strategies to Enhance Wound Healing in Frail Elders
When meeting with a new patient, wound care professionals often focus on vital signs, oxygen saturation, medications, wound characteristics, and other clinical concerns. Although all of these are important to the recovery process, healing can be helped or hindered by the patient’s nutritional status, which often is not evaluated. The cause of poor nutrition in the elderly appears to be multifactorial and reflects physical and physiological limitations and psychosocial changes. Patients who are malnourished experience more complications and infections, which worsen their medical condition and decrease their survival rate.1 The accumulated effects of immobility, poor nutritional intake, and immune system challenges increase an elderly patient’s risk for pressure ulcers by 74%.2 For an already malnourished elderly patient with comorbidities, a pressure ulcer can be life-threatening. Although adequate dietary intake is important for all individuals, meeting the patient’s nutrient needs is even more important when a wound is present. This article will discuss various factors that hinder nutritional status and provide practical strategies to optimize nutrient intake and enhance wound healing.
Factors that Contribute to Poor Nutritional Status
Change in body composition. The major age-related change in the elderly is muscle atrophy, also known as sarcopenia. From the Greek meaning poverty of flesh, sarcopenia is the degenerative loss of skeletal muscle mass and strength associated with aging. It begins in the third decade of life and accelerates with advancing age; it really speeds up after a person’s 75th birthday. It is a component of the frailty syndrome and can be debilitating and even fatal for the elderly, especially in the face of other comorbidities. At the root of sarcopenia is the issue of body composition. For simplicity, lean body mass (LBM) is defined as “the mass of the body minus the fat.” LBM is crucial for wound healing, immunity, organ function, and muscle strength. Loss of LBM occurs with aging, immobilization, acute injury or surgery, poor diet, lack of activity, and chronic health conditions. If a person who already has a deficiency of muscle mass suffers an additional insult from trauma or a chronic disease process, recovery of normal independent function is very difficult if not unlikely. Proper nutrition can help, particularly protein intake.
Physical limitations. Changes in the oral cavity such as decreased salivary production, chewing or swallowing difficulties, ill-fitting dentures, missing teeth, or fatigue with eating can have a substantial impact on the quantity and quality of foods the patient chooses to eat. Immobility, visual impairment, decreased hand strength, or self-feeding deficit can affect a person’s ability to shop, prepare, and consume certain foods. An estimated 42% of people over the age of 65 years have limitations in performing one or more daily tasks that are essential for independence, such as transferring from sitting to standing, grocery shopping, or housekeeping.3 A decrease in taste perception and sense of smell occurs with age and results in a disinterest in food and decreased appetite. Complicating matters further, bed rest or decreased physical activity contributes to loss of LBM and compromised skin integrity, which may ultimately result in pressure wounds.
Chronic illness. Although medical conditions affect individuals of all ages, elderly patients are more likely to have multiple illnesses coupled with cognitive impairment and/or incontinence. Common conditions associated with decreased appetite and malnutrition include diabetes, renal impairment, cancer, HIV/AIDS, and cardiac disorders. Gastrointestinal disturbances such as abdominal pain, nausea, vomiting, diarrhea, and malabsorptive conditions can inhibit one’s appetite. Importantly, elderly patients often are prescribed multiple medications that may hinder taste and/or appetite, cause malabsorption, or increase nutrient losses, resulting in a loss of desire to eat.
Psychosocial factors. Impaired cognition, confusion, and social isolation have a notable impact on a patient’s nutritional status. Additionally, factors such as loneliness or depression, frustration, anger, confusion, and fear of incontinence can limit nutritional intake. A lack of transportation and financial restraints often can leave a patient feeling helpless and depressed. Elderly patients can experience forgetfulness, anxiety, and sleep disturbances that may have implications for poor eating habits. Loss of loved ones and a decrease in independence can hinder a patient’s emotional stability and desire to eat.
Enhancing Wound Healing
Dietary interventions aimed at meeting the nutritional needs of aging people should emphasize the value of high-quality, nutrient-dense foods that meet both caloric and protein needs, with the goal to preserve or restore muscle mass. When a wound develops, protein and calorie needs are significantly increased. Preventing loss of LBM by providing adequate calories and carbohydrates is crucial to allow protein to facilitate the wound healing process. When nutritional intake is suboptimal, wound healing and LBM restoration compete for nutrients. Therefore, it is important to provide adequate protein and calories to rebuild tissue and prevent muscle wasting. Early dietary intervention, targeted at wound healing, is imperative.
Protein and calories are needed in the correct amounts each day to fuel the body’s recovery. If your patient consumes too little, it will lead to unintended weight loss and loss of lean muscle mass and, in turn, loss of independence and possibly a rehospitalization. A recent study4 demonstrated that pre-existing malnutrition/weight loss increased the odds of developing a pressure ulcer 3.8 times. It is important to stress proper nutritional intake at the very first office, clinic, or hospital visit to expedite recovery. One study5 showed that elderly people who had empty refrigerators were more frequently admitted to the hospital than those with adequate food contents. Asking a few questions about the patient’s appetite and observing available meals and food items in the home care setting can easily be worked in without adding extra time to the assessment. Look in the refrigerator and pantry each visit and see if the patient has food items on hand to prepare healthy meals. Make sure the patient has a scale available and is monitoring for weight changes regularly. Inquire about assistance needed for grocery shopping, meal planning, and food preparation tasks. To meet protein needs, encourage a serving of eggs, beef, chicken, pork, or fish at each meal. Eggs are inexpensive and easy to prepare, which make them an ideal source of complete protein. To meet caloric needs, suggest small meals throughout the day if appetite is a problem. Meals do not have to be elaborate; stick to basic menus that are appealing and comforting to the patient. Cooking extra portions for the next day can save time. Encourage socialization at meal time, which can help with both intake and mood.
It is recommended that protein be spread evenly throughout the day as opposed to eating the vast majority of protein at a single meal. Simply put, a breakfast of tea and toast does not maximize protein synthesis. Protein should be included at every meal. Good sources of protein include lean meat, poultry, cheese, eggs, nuts and seeds, milk, and yogurt. For patients who have a poor appetite, oral nutrition supplements (ONS) can fill in the gaps and generally provide 8–15 g of protein per serving. According to one study,6 a 3-month intervention with ONS showed an increase in quality of life in malnourished patients. For example, Ensure® contains 9 g of protein, Ensure® Plus and Clinical Strength contain 13 g of protein, and Ensure® High Protein Shakes contain 25 g of protein (Abbott Nutrition, Columbus, OH). Most patients are accepting of this type of supplement to meet their elevated nutrient needs in a convenient manner.
When a patient is sick or dealing with a chronic illness or wound, he/she often feels weak and tired and may not have the strength necessary to shop and prepare meals. It is important to emphasize proper meal intake because calories, protein, and fluids are critical to healing and regaining independence. The patient should consume nutrient-dense foods and eat and drink as healthfully as possible every day during his/her recovery. ONS can play a role to conveniently fill the nutrient gaps. Table 1 contains helpful tips to maintain adequate nutritional status practitioners can easily relay to patients during the course of a visit. If the patient requires more complex nutritional assessment and treatment, he/she should be referred to a registered dietitian (RD).
Poor nutrition can arise from a variety of factors and can lead to a vicious cycle of weakness and loss of LBM, resulting in skin breakdown and recurrent hospitalizations. Quality of life becomes hindered when one’s nutritional status is compromised. In one study,7 institutionalized elderly patients who lost 5% of their body weight in 1 month were found to be four times more likely to die within one year. Healthcare professionals should key into signs of decreased oral intake or feeding difficulties and suggest appropriate compensatory strategies. Every effort should be made to enhance the patient’s nutritional status to prevent loss of LBM and optimize skin integrity. As Hippocrates said: “Let food be thy medicine, and medicine be thy food.”
Nancy Collins, PhD, RD, LD/N, FAPWCA, is founder and executive director of Nutrition411.com and Wounds411.com. For the past 20 years, she has served as a consultant to healthcare institutions and as a medico-legal expert to law firms involved in healthcare litigation. Colleen Sloan, RD, LD/N, is a clinical dietitian at Delray Medical Center, Delray Beach, FL; and President of 360 Nutrition Solutions. Colleen also serves as a consultant dietitian to the Joe DiMaggio Children’s Hospital, Hollywood, FL; and she is a contributor and member of the management team for Nutrition411.com. Correspondence may be sent to Dr. Collins at NCtheRD@aol.com. This article was not subject to the Ostomy Wound Management peer-review process.
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