- Email: [email protected]
Nutritional support of the elderly cancer patient: The role of the nurse
Nutrition 31 (2015) 598–602
Contents lists available at ScienceDirect
Nutrition journal homepage: www.nutritionjrnl.com
Special article
Nutritional support of the elderly cancer patient: The role of the nurse Jane B. Hopkinson Ph.D., R.G.N. * School of Healthcare Sciences, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
a r t i c l e i n f o
a b s t r a c t
Article history: Received 20 November 2014 Accepted 23 December 2014
Cancer in the geriatric population is a growing problem. Malnutrition is common in cancer. A number of factors increase the risk for malnutrition in older people with cancer, including chronic comorbid conditions and normal physiological changes of aging. Nurses have an important role in the nutritional support of older cancer patients. To contribute to the improvement of nutritional support of these patients, nurses need appropriate training to be able to identify risk for malnutrition and offer a range of interventions tailored to individual need. Factors to consider in tailoring interventions include disease status, cancer site, cancer treatment, comorbidity, physiological age, method of facilitating dietary change, and family support. This article identifies ways in which nurses can contribute to the nutritional support of older cancer patients and thus help mitigate the effects of malnutrition. Ó 2015 Elsevier Inc. All rights reserved.
Keywords: Nutritional care Cancer Elderly Education and training Nurse
Introduction Cancer in older people is a growing problem. In almost every country, the proportion of individuals aged >60 y is growing faster than any other age group and is forecast to reach 2 billion by 2050 [1]. Cancer is primarily a disease of older people [2]. It is estimated that by 2050 in the United States, 42% of the cancer population will be 75 y [3]. Currently, in the United Kingdom, 63% cancers are diagnosed in people ages 65 [2]. The prevalence of malnutrition in cancer patients is reported to range from 33% to 85%, depending on cancer site and stage of disease [4]. Malnourishment is associated with poor clinical outcomes that include greater morbidity and mortality, reduced quality of life, and increases in hospitalization and hospital length of stay [5]. A number of factors increase the risk for malnutrition in older people with cancer. These include chronic comorbid conditions and normal physiological changes of aging that can have a negative affect on nutritional intake, such as functional impairment, poor sight, and loss of taste. Nurses are an important interface between patients and health services. All patients meet nurses across their cancer
Jane Hopkinson is a member of the Scientific Board, Cachexia Hub, Helsinn Healthcare. * Corresponding author. Tel.: þ44 292 091 7813; fax: þ44 292 091 7803. E-mail address: [email protected] http://dx.doi.org/10.1016/j.nut.2014.12.013 0899-9007/Ó 2015 Elsevier Inc. All rights reserved.
journey. Nurses have an important role to play in the nutritional support of older cancer patients. This article identifies ways in which nurses can contribute to the nutritional support of these patients and thus help mitigate the effects of malnutrition. To enable nurses to provide nutritional support, they must be able to use indicators of nutrition risk and act on them appropriately. Using indicators of nutrition risk Tools have been designed and validated to identify individuals with cancer who are malnourished, or at risk for malnutrition. These screening tools are used to grade or score nutritional status. The grade or score is then used to inform clinical intervention. The Patient-Generated Subjective Global Assessment [6], the Mini Nutritional Assessment (MNA) [7], and the Malnutrition Universal Screening Tool [8] are examples of screening tools validated in cancer patients. These tools have been designed to provide a simple and rapid assessment of nutritional status. MNA has been designed specifically for older cancer patients. Each tool combines information on indicators of nutrition risk, such as involuntary weight loss, poor food intake, low body mass index, acute illness, symptoms that affect food intake (e.g., nausea) and distress, to identify patients who may benefit from nutritional support.
J. B. Hopkinson / Nutrition 31 (2015) 598–602
It should be remembered that nutritional risk indicators in older cancer patients, such as involuntary weight loss, could be caused by many factors. Some, but not all, factors are cancerrelated. First, a nutritional risk indicator may not be caused by undernutrition, but rather by cancer cachexia syndrome. It would thus be a consequence of tumor-induced metabolic change, which is more likely with some cancers such as pancreatic cancer. A second reason for a nutritional risk indicator can be the cancer treatment. For example, systemic chemotherapy can cause nausea that affects food intake. Alternatively, nutritional risk indicators in older cancer patients can be the consequence of the normal aging process. In the geriatric population, there is a propensity for unintentional weight loss and a protein-deficient diet [9], in part because of age-related changes such as changes in taste. Other significant age-related changes include the loss of cognitive function and deteriorating vision, all of which hinder good health and dietary habits in this age group [10]. It is important to remember that physiological age differs from chronologic age; “as people grow old, the probability of important losses of function increases, but the ageing process remains highly individual” [11]. It is a mistake to assume that someone of a certain age actually has a problem that is associated with age, such as loss of appetite. Finally, it is likely than older people with cancer will also have comorbid conditions common in the age group and impacting nutritional status, such a depression. Indicators of nutrition risk can thus have different underlying causes. Existing standards and protocols for nutritional care may not be appropriate for those with palliative care needs, when disease is the most likely cause of any identified nutritional risk. In this situation, wider issues need to be taken into account to address the patient’s psychological and social malnutrition [12]. It is difficult to make judgments about the likelihood of nutritional intervention having benefit in patients with incurable disease. One approach is for the judgment to be a multidisciplinary team decision, based on discussion and consensus agreement [13]. Given the potential for multiple causes of nutritional risk in older cancer patients, many of which cannot be identified using a tool that screens for risk of malnutrition or actual malnutrition, an alternative approach should perhaps be considered. The comprehensive geriatric assessment (CGA) is one possibility. The CGA typically includes assessment of nutritional status but also assesses for a wide range of other factors that can affect nutritional status, such as frailty and polypharmacy. Knowledge from both geriatrics and oncology may be needed to provide appropriate nutritional support to older cancer patients [14]. Recognition of the need for other members of the health care team to contribute to the nutritional support of the older cancer patient is an important nursing role. Most often, this would be identification of a need to refer the patient to a specialist dietitian. However, it also could include consideration of involving other allied health care professionals and/or experts from other fields, such as gerontology. In summary, indicators of nutritional risk that can alert nurses and the multidisciplinary teams of a need for nutritional support include:
Low body mass index Evidence of involuntary weight loss Loss of appetite Changes to the experience of eating (e.g., changes in taste or to texture)
599
Physical barriers to the act of eating (e.g., dysphasia or nausea) Barriers to the absorption of food (e.g., vomiting or diarrhea) Concern about eating expressed by the patient or family member Mental health barriers (e.g., depression or confusion) Exacerbating factors (e.g., frailty, medications, lack of social support, or poor dental health) In clinical practice, it is difficult to know if indicators of malnutrition are due to age, disease, comorbidity, or undernutrition. Nutritional support is usually warranted to test if presenting problems are due to undernutrition and can therefore be arrested or reversed. Nurse-supported interventions Nurses can be trained to offer nutritional advice and this has been found acceptable to patients [15–17]. There is also evidence that supportive nutritional care offered by nurses can have a positive effect on patient behavior and health outcomes (Table 1). Randomized controlled trials have found nurse-delivered nutritional counseling to slow decline in performance status in cancer patients [18] (Dixon 1984) and to improve physical function and depression in patients with angina [19]. A Cochrane review found no evidence of nutritional advice from a nurse versus a dietitian being inferior in lowering blood cholesterol [20]. Nurse-delivered approaches found to have benefit include providing information and advice and involving family caregivers in the patient’s nutritional care. Running alongside these approaches is a need to tailor interventions to each patient’s physiological, psychological, and social circumstances. The purposes of intervention may differ depending on whether the patient is undergoing curative treatment, palliative treatment, or is in a position of survivorship post-curative treatment. The primary purpose of an eating intervention delivered to a patient with advanced cancer might be to improve the patient’s quality of life. In this circumstance, the nutritional balance of food intake might be less important than helping the patient to identify what he or she can eat [21]. For a colorectal cancer patient receiving treatment, the goal should be improvement in nutritional status [22], whereas for a breast cancer survivor, the goal is to support a healthy diet and lifestyle that reduces the risk for recurrence and other morbidity [23]. What is appropriate support will thus differ according to disease stage, cancer site, and whether or not the person is receiving treatment. Intervention choices also should take into account available social support and the implications of comorbidity. Actions required by nurses also may include overcoming barriers that may prevent patients receiving adequate food and drink [24], such as frailty. Eating well with cancer and support for eating well is not the same for all cancer patients. Information and advice Nutritional counseling can be described as the use of education informed by psychological theory to facilitate changes in eating behavior. Its importance for people with cancer is to encourage optimal dietary intake to minimize nutritional risk, while taking into account individual circumstances, such as food preferences. Tailoring advice to individual patient need is an essential part of the process of facilitating dietary change. Consideration should be given to use of theory-based approaches to behavioral change to communicate nutritional information
600
J. B. Hopkinson / Nutrition 31 (2015) 598–602
Table 1 Examples of nurse involvement in the nutritional support of older patients Author (y)
Description of study
Nutritional support provided by nurses
Impact on patient health outcomes
Young et al. (2011) [25].
Systematic review of nutritional intervention for community-dwelling older people: 23 RCTs (each recruiting from 22–2558 people age 65 y)
Nutritional education was provided solely by nurses in 10 of the studies either alone or as part of a complex intervention.
Baldwin and Weeks (2011) [26].
Systematic review of dietary advice with or without nutritional supplements in disease-related malnutrition: 45 RCTs (3186 participants)
Nutritional counseling was delivered by nurses in one study to participants mean age 60 [18].
Hopkinson et al. (2010) [27].
An exploratory trial of the MAWE, a psychosocial intervention that includes nutritional counseling: 25 advanced cancer patients, median age 69 y
Nurses delivered complex intervention that included a nutritional counseling component supported by information leaflets
Kennelly et al. (2010) [28].
Evaluation of an education program to improve the management of malnourished patients in the community: 82 nurse participants
Nurses used MUST and offered dietary advice
The review found that nutritional education or advice can improve physical function, improve diet and, as a component of a complex intervention, reduce depression. Nutritional education or advice provided by nurses was found to improve physical function and mental health/emotional well-being in 5 of 6 of the studies where these were measured outcomes. The review found dietary advice, with or without oral nutritional supplements may improve weight, body composition and grip strength. The study of nurse-delivered nutritional counseling found slower decline in performance status compared with a control group. Patients reported change in the type of foods eaten to those that were nutrition dense and easy to eat. They also increased the number of times they ate during the day. Nurses self-reported improved management of malnourished patients, for example, giving dietary advice more often.
MAWE, Macmillan Approach to Weight and Eating; MUST, Malnutrition Universal Screening Tool; RCT, randomized controlled trial.
(e.g., motivational interviewing, therapeutic story telling). Table 2 lists examples of advice nurses can offer patients in the context of nutritional counseling. (Note: The recommendations are based mainly on studies of malnourished older people, as cancer-specific studies have yet to be conducted). Involving family caregivers in nutritional care The MAWE (Macmillan Approach to Weight and Eating) studies research program carried out in the United Kingdom
found that family members influence the eating behaviors of patients with advanced cancer. In some cases, this influence was helpful. But in others, disagreements within the family about food and eating could be detrimental to both quality of life and the patient’s nutritional intake [29]. Typically, these disagreements were fueled by uncertainty about what best to do. Nurses may be able to reduce nutritional risk in cancer patients by offering supportive nutritional interventions not only to the patient, but also by involving their family caregiver. Raising family members’ awareness of potential barriers and obstacles to
Table 2 Advice nurses should consider offering cancer patients Try sip feeds and other supplements
Take regular foods that are nutritionally dense
Try high-protein oral nutritional supplements
Take supplements between meals Eat when most hungry (typically early morning) Eat energy- and protein-rich foods (e.g., full-fat dairy) Follow a diet that is easy to eat (i.e., soft and moist) Try cold foods (if the smell of food is a problem) Experiment with flavors (if taste is a problem) Try sipping fluid with food (if dry mouth is a problem) Try preprepared food (if fatigue is a problem) Misunderstandings can contribute to poor nutrition, such as the belief that hot foods are of greater nutritional value than cold
Supplements (protein and energy usually as sip feeds) produce a small but consistent weight gain in older people. Mortality may be reduced in older people who are malnourished [30]. Counseling with regular foods is of benefit in improving nutritional status, reducing treatment toxicity, and improving quality of life in patients with colorectal cancer treated with radiotherapy. [22]. The American Dietetic Association recommends that the quality of life and nutritional status of older adults residing in health care communities can be enhanced by individualization to less-restrictive diets tailored according to each person’s individual medical condition, needs, desires, and rights [31]. Systematic review involving 36 randomized controlled trials (N ¼ 3790; mean age 74 y) effects across settings and patient groups in favor of the high-protein oral nutritional supplements. These include reduced hospital readmissions; improved grip strength; increased intake of protein and energy with little reduction in normal food intake, and improvements in weight [32]. Expert opinion of author [33]. Recommendations for cancer patients with eating problems made by experts in professional journals [34]
Expert opinion of authors based on clinical and research practice [35].
J. B. Hopkinson / Nutrition 31 (2015) 598–602
receiving adequate food and drink could be an important role for nurses. Nurses should perhaps give family caregivers guidance on food choices, patient positioning, and appropriate assistance with feeding.
The need to improve nurse education in the provision of nutritional support Although it might be assumed that the provision of nutritional support to cancer patients has intuitively obvious benefits, this may not be so. For example, of 40 cancer patients recruited into a study in New Zealand, not one reported receiving dietary information from the doctor or nurse [36]. Similarly, studies on patients with advanced cancer in the United Kingdom have identified a culture of weight loss taboo that inhibited nutritional intervention [37] and inconsistent management of symptoms that can affect nutritional status [38]. In Austria, a survey of hospital patients (n ¼ 2326) and nursing homes residents (n ¼ 1487) found the prevalence of malnutrition was high but guidelines for its management were used infrequently, with a substantial number of patients or residents receiving no nutritional intervention [39]. Australian practice nurses have been found to recognize the importance of nutrition to chronic disease management but to be unsure of the effectiveness of the nutritional advice they give and to believe additional nutritional education would help them provide nutritional care [40]. A questionnaire survey conducted in Australia found only 39% (n ¼ 2759) of nurses to consider their basic nutritional education sufficient [41]. Similarly, nurses and student nurses in the United States recognized the importance of nutritional care but lacked knowledge in the nutritional management of diabetes and believed they would benefit from additional nutritional education [42]. In 2009, the British Association for Parenteral and Enteral Nutrition published a report that highlighted the need for education and training if patients are to receive appropriate nutritional care, support, and treatment [43]. There is evidence of a gap in the training of nurses, which suggests a lack of confidence and competence in offering nutritional support may explain their observed lack of engagement in delivering nutritional interventions. It has been noted that nutrition is included as only a small part of a broader nursing education [9]. Yet nutritional education can make a difference to the provision of supportive nutritional care. For example, evaluation of a training program for 16 hospital nurses found that after 12 mo they were more confident in nutritional management and exhibited a greater awareness of and responsibility for nurse-specific intervention [44].
Conclusion This article identified a number of ways in which nurses can contribute to the nutritional support of older cancer patients. Nurses must be able to recognize common indicators of nutrition risk and be able to tailor their support to the needs of individual patients. In the absence of such support, patients and their families may be uncertain as to how to approach eating issues. Such uncertainty is a potential cause of family disagreements and may increase the prevalence of the use of inappropriate advice from nonexperts. But, although there is much potential for nurses to contribute to the nutritional support of older cancer patients, there are also significant opportunities for the improvement of training and practice.
601
References [1] World Health Organisation 2013, Health topics: ageing. Available at: http:// www.who.int/topics/ageing/en/. Accessed January 9, 2015. [2] Cancer Research UK 2012, Cancer incidence by age. Available at: http://www. cancerresearchuk.org/cancer-info/cancerstats/incidence/age/. Accessed January 9, 2015. [3] Edwards BK, Howe HL, Ries LAG, Thun MJ, Rosenberg HM, Yancik R, et al. Annual report to the nation on the status of cancer 1973 to 1999, featuring implications of age and ageing on U.S. cancer burden. Cancer 2002;94:2766–92. [4] Stratton RJ, Green CJ, Elia M. Disease related malnutrition: an evidence based approach to treatment. Oxford: CABI Publishing; 2003. [5] British Dietetic Association. Malnutrition. In: Thomas B, Bishop J, editors. Manual of dietetic practice. Oxford, UK: Blackwell Publishing Limited; 2007. p. 80–90. [6] Ottery FD. Definition of standardized nutritional assessment and interventional pathways in oncology. Nutrition 1996;12(Suppl 1):S15–9. [7] Vellas B, Guigoz Y, Garry PJ, Nourhashemi F, Lauque S, Albarede JL. The Mini Nutritional Assessment (MNA) and its use in grading the nutritional state of elderly patients. Nutrition 1999;15:116–22. [8] Stratton RJ, Hackston A, Longmore D, Dixon R, Price S, Stroud M, et al. Malnutrition in hospital outpatients and inpatients: prevalence, concurrent validity and ease of use of the “malnutrition universal screening tool” (MUST) for adults. Br J Nutr 2004;92:799–808. [9] Henning M. Nursing’s role in nutrition. Comput Inform Nurs 2009;27:301–6. [10] World Health Organisation. Nutrition for older persons - keep fit for life. Meeting the nutritional needs of older persons. Available at: http:// www.who.int/nutrition/topics/ageing/en/index1.html. Accessed January 9, 2015. [11] Lazarus RS. Stress and emotion: a new synthesis. London: Free Association Press; 1999. [12] Muir CI, Linklater GT. A qualitative analysis of the nutritional requirements of palliative care patients. J Hum Nutr Diet 2011;24:470–8. [13] Hawkins C, Andrews I, Aston T, Beyer T, Cairns J, Hansford B, et al. Multidisciplinary approach to nutritional problems. In: del Fabbro E, Bruera E, Demark-Wahnefried W, Bowling T, Hopinson JB, Baracos VE, editors. Nutrition and the cancer patient. Oxford: Oxford University Press; 2010. p. 237–54. [14] Gosney M. General care of the older cancer patient. Clin Oncol 2009;21:86–91. [15] Hopkinson JB, Fenlon D, Nicholls P, Wright D, Okamoto I, Roffe L, et al. Helping people live with advanced cancer: an exploratory cluster randomised trial to investigate the effectiveness of the “Macmillan Approach to Weight loss and Eating difficulties: (MAWE)”. London: Macmillan Cancer Support; 2008. [16] Kennelly S, Kennedy NP, Corish CA, Flanagan-Rughoobur G, GlennonSlattery C, Sugrue S. Sustained benefits of a community dietetics intervention designed to improve oral nutritional supplement prescribing practices. J Hum Nutr Diet 2011;24:496–504. [17] Kim S, Shin MS, Lee HS, Lee ES, Ro JS, Kang HS, et al. Randomized pilot test of simultaneous exercise and diet intervention for breast cancer survivors. Oncol Nurs Forum 2011;38:E97–106. [18] Dixon J. Effect of nursing interventions on nutritional and performance status in cancer patients. Nursing Research 1984;33(6):330–5. [19] Lewin RJ, Furze G, Robinson J, Griffiths K, Wiseman S, Pye M, et al. A randomised controlled trial of a self-management plan for patients with newly diagnosed angina. Br J Gen Pract 2002;52:194–6. 199–201. [20] Thompson RL, Summerbell CD, Hooper L, Higgins JPT, Little P, Talbot D, et al. Dietary advice given by a dietitian versus other health professional or self-help resources to reduce blood cholesterol. Cochrane Database Syst Rev; 2003:CD001366. [21] Hopkinson JB, Okamoto I, Addington-Hall J. What to eat when off treatment and living with involuntary weight loss and cancer: a systematic search and narrative review. Support Care Cancer 2011;19:1–17. [22] Ravasco P, Monteiro-Grillo P, Camila M. Individualized nutrition intervention is of major benefit to colorectal cancer patients: long-term follow-up of a randomized controlled trial of nutritional therapy. Am J Clin Nutr 2012;96:1346–53. [23] Demark-Wahnefried W, Clipp EC, Lipkus IM, Lobach D, Snyder DC, Sloane R, et al. Main outcomes of the FRESH START trial: a sequentially tailored, diet and exercise mailed print intervention among breast and prostate cancer survivors. J Clin Oncol 2007;25:2709–18. [24] Bloomfield J, Pengram A. Improving nutrition and hydration in hospital: the nurses’ responsibility. Nurs Stand 2012;26:52–6. [25] Young K, Bunn F, Trivedi D, Dickinson A. Nutritional education for community dwelling older people: a systematic review of randomised controlled trials. Int J Nurs Stud 2011;48:751–80. [26] Baldwin C, Weeks CE. Dietary advice with or without oral nutritional supplements for disease-related malnutrition in adults. Cochrane Database Syst Rev; 2011:CD002008. [27] Hopkinson JB, Fenlon DR, Okamoto I, Wright DNM, Scott I, AddingtonHall J, et al. The Macmillan Approach to Weight loss and Eating difficulties
602
[28]
[29] [30]
[31]
[32]
[33] [34] [35]
J. B. Hopkinson / Nutrition 31 (2015) 598–602 (MAWE): a phase II cluster randomised exploratory trial of a psychosocial intervention for weight and eating related distress in people with advanced cancer. J Pain Symptom Manage 2010;40:684–95. Kennelly S, Kennedy NP, Rughoobur GF, Slattery CG, Sugrue S. An evaluation of a community dietetics intervention on the management of malnutrition for healthcare professionals. J Hum Nutr Diet 2010;23:567–74. Hopkinson JB. Caregivers’ influence on diets of people with advanced cancer. Nurs Times 2008;104:28–9. Milne AC, Potter J, Vivanti A, Aveneli A. Protein and energy supplementation in elderly people at risk from malnutrition. Cochrane Database Syst Rev; 2009:CD003288. American Dietetic Association. Practice paper of the American Dietetic Association: individualized nutrition approaches for older adults in health care communities. J Am Diet Assoc 2010;110:1554–62. Cawood AL, Elia M, Stratton RJ. Systematic review and meta-analysis of the effects of high protein oral nutritional supplements. Ageing Res Rev 2011;11:278–96. Morley JE. Calories and cachexia. Curr Opin Clin Nutr Metab Care 2009;12:607–10. Hopkinson JB. Change in eating habits. In: Corner J, Bailey C, editors. Cancer nursing: care in context. Victoria: Blackwell; 2008. p. 525–32. Hopkinson JB, Strasser F. Psychosocial aspects of nutrition. In: van Halteren H, Jatoi A, editors. Nutrition and cancer. Viganello-Lugano, Switzerland: ESMO Press; 2011. p. 73–80.
[36] Pullar J, Chisholm A, Jackson C. Dietary information for colorectal cancer survivors: an unmet need. N Z Med J 2012;125:27–37. [37] Hopkinson JB, Wright DNM, Corner JL. The experience of weight loss in people with advanced cancer. J Adv Nurs 2006;54:304–12. [38] Churm D, Andrew I, Holden K, Hawkins C. A questionnaire study of the approach to anorexia-cachexia syndrome in patients with cancer by staff in a district general hospital. Support Care Cancer 2009;17:503–7. [39] Schonherr S, Halfens RJG, Meijer JMM, Schols JMGA, Lohrmann C. Structural and process indicators of nutritional care: a comparison between Austrian hospitals and nursing homes. Nutrition 2012;28:868–73. [40] Martin L, Leveritt MD, Desbrow B, Ball LE. The self-perceived knowledge, skills and attitudes of Australian practice nurses in providing nutrition care to patients with chronic disease. Fam Pract 2014;31:201–8. [41] Johansson U, Rasmussen HH, Mowe M, Staun M, Scandinavian Nutrition Group. Clinical nutrition in medical gastroenterology: room for improvement. Clin Nutr 2009;28:129–33. [42] Carney T, Stein SE, Quinlan JJ. The need of additional training for nutritional management of diabetes. Br J Nurs 2013;22:512. 514–7. [43] Elia M, Smith RM, Improving nutritional care and treatment Perspectives and Recommendations from Population Groups, Patients and Carers. A report from BAPEN. 2009. [44] Bjerrum M, Tewes M, Pedersen P. Nurses’ self-reported knowledge about and attitude to nutritiondbefore and after a training programme. Scand J Caring Sci 2011;26:81–9.
Contents lists available at ScienceDirect
Nutrition journal homepage: www.nutritionjrnl.com
Special article
Nutritional support of the elderly cancer patient: The role of the nurse Jane B. Hopkinson Ph.D., R.G.N. * School of Healthcare Sciences, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
a r t i c l e i n f o
a b s t r a c t
Article history: Received 20 November 2014 Accepted 23 December 2014
Cancer in the geriatric population is a growing problem. Malnutrition is common in cancer. A number of factors increase the risk for malnutrition in older people with cancer, including chronic comorbid conditions and normal physiological changes of aging. Nurses have an important role in the nutritional support of older cancer patients. To contribute to the improvement of nutritional support of these patients, nurses need appropriate training to be able to identify risk for malnutrition and offer a range of interventions tailored to individual need. Factors to consider in tailoring interventions include disease status, cancer site, cancer treatment, comorbidity, physiological age, method of facilitating dietary change, and family support. This article identifies ways in which nurses can contribute to the nutritional support of older cancer patients and thus help mitigate the effects of malnutrition. Ó 2015 Elsevier Inc. All rights reserved.
Keywords: Nutritional care Cancer Elderly Education and training Nurse
Introduction Cancer in older people is a growing problem. In almost every country, the proportion of individuals aged >60 y is growing faster than any other age group and is forecast to reach 2 billion by 2050 [1]. Cancer is primarily a disease of older people [2]. It is estimated that by 2050 in the United States, 42% of the cancer population will be 75 y [3]. Currently, in the United Kingdom, 63% cancers are diagnosed in people ages 65 [2]. The prevalence of malnutrition in cancer patients is reported to range from 33% to 85%, depending on cancer site and stage of disease [4]. Malnourishment is associated with poor clinical outcomes that include greater morbidity and mortality, reduced quality of life, and increases in hospitalization and hospital length of stay [5]. A number of factors increase the risk for malnutrition in older people with cancer. These include chronic comorbid conditions and normal physiological changes of aging that can have a negative affect on nutritional intake, such as functional impairment, poor sight, and loss of taste. Nurses are an important interface between patients and health services. All patients meet nurses across their cancer
Jane Hopkinson is a member of the Scientific Board, Cachexia Hub, Helsinn Healthcare. * Corresponding author. Tel.: þ44 292 091 7813; fax: þ44 292 091 7803. E-mail address: [email protected] http://dx.doi.org/10.1016/j.nut.2014.12.013 0899-9007/Ó 2015 Elsevier Inc. All rights reserved.
journey. Nurses have an important role to play in the nutritional support of older cancer patients. This article identifies ways in which nurses can contribute to the nutritional support of these patients and thus help mitigate the effects of malnutrition. To enable nurses to provide nutritional support, they must be able to use indicators of nutrition risk and act on them appropriately. Using indicators of nutrition risk Tools have been designed and validated to identify individuals with cancer who are malnourished, or at risk for malnutrition. These screening tools are used to grade or score nutritional status. The grade or score is then used to inform clinical intervention. The Patient-Generated Subjective Global Assessment [6], the Mini Nutritional Assessment (MNA) [7], and the Malnutrition Universal Screening Tool [8] are examples of screening tools validated in cancer patients. These tools have been designed to provide a simple and rapid assessment of nutritional status. MNA has been designed specifically for older cancer patients. Each tool combines information on indicators of nutrition risk, such as involuntary weight loss, poor food intake, low body mass index, acute illness, symptoms that affect food intake (e.g., nausea) and distress, to identify patients who may benefit from nutritional support.
J. B. Hopkinson / Nutrition 31 (2015) 598–602
It should be remembered that nutritional risk indicators in older cancer patients, such as involuntary weight loss, could be caused by many factors. Some, but not all, factors are cancerrelated. First, a nutritional risk indicator may not be caused by undernutrition, but rather by cancer cachexia syndrome. It would thus be a consequence of tumor-induced metabolic change, which is more likely with some cancers such as pancreatic cancer. A second reason for a nutritional risk indicator can be the cancer treatment. For example, systemic chemotherapy can cause nausea that affects food intake. Alternatively, nutritional risk indicators in older cancer patients can be the consequence of the normal aging process. In the geriatric population, there is a propensity for unintentional weight loss and a protein-deficient diet [9], in part because of age-related changes such as changes in taste. Other significant age-related changes include the loss of cognitive function and deteriorating vision, all of which hinder good health and dietary habits in this age group [10]. It is important to remember that physiological age differs from chronologic age; “as people grow old, the probability of important losses of function increases, but the ageing process remains highly individual” [11]. It is a mistake to assume that someone of a certain age actually has a problem that is associated with age, such as loss of appetite. Finally, it is likely than older people with cancer will also have comorbid conditions common in the age group and impacting nutritional status, such a depression. Indicators of nutrition risk can thus have different underlying causes. Existing standards and protocols for nutritional care may not be appropriate for those with palliative care needs, when disease is the most likely cause of any identified nutritional risk. In this situation, wider issues need to be taken into account to address the patient’s psychological and social malnutrition [12]. It is difficult to make judgments about the likelihood of nutritional intervention having benefit in patients with incurable disease. One approach is for the judgment to be a multidisciplinary team decision, based on discussion and consensus agreement [13]. Given the potential for multiple causes of nutritional risk in older cancer patients, many of which cannot be identified using a tool that screens for risk of malnutrition or actual malnutrition, an alternative approach should perhaps be considered. The comprehensive geriatric assessment (CGA) is one possibility. The CGA typically includes assessment of nutritional status but also assesses for a wide range of other factors that can affect nutritional status, such as frailty and polypharmacy. Knowledge from both geriatrics and oncology may be needed to provide appropriate nutritional support to older cancer patients [14]. Recognition of the need for other members of the health care team to contribute to the nutritional support of the older cancer patient is an important nursing role. Most often, this would be identification of a need to refer the patient to a specialist dietitian. However, it also could include consideration of involving other allied health care professionals and/or experts from other fields, such as gerontology. In summary, indicators of nutritional risk that can alert nurses and the multidisciplinary teams of a need for nutritional support include:
Low body mass index Evidence of involuntary weight loss Loss of appetite Changes to the experience of eating (e.g., changes in taste or to texture)
599
Physical barriers to the act of eating (e.g., dysphasia or nausea) Barriers to the absorption of food (e.g., vomiting or diarrhea) Concern about eating expressed by the patient or family member Mental health barriers (e.g., depression or confusion) Exacerbating factors (e.g., frailty, medications, lack of social support, or poor dental health) In clinical practice, it is difficult to know if indicators of malnutrition are due to age, disease, comorbidity, or undernutrition. Nutritional support is usually warranted to test if presenting problems are due to undernutrition and can therefore be arrested or reversed. Nurse-supported interventions Nurses can be trained to offer nutritional advice and this has been found acceptable to patients [15–17]. There is also evidence that supportive nutritional care offered by nurses can have a positive effect on patient behavior and health outcomes (Table 1). Randomized controlled trials have found nurse-delivered nutritional counseling to slow decline in performance status in cancer patients [18] (Dixon 1984) and to improve physical function and depression in patients with angina [19]. A Cochrane review found no evidence of nutritional advice from a nurse versus a dietitian being inferior in lowering blood cholesterol [20]. Nurse-delivered approaches found to have benefit include providing information and advice and involving family caregivers in the patient’s nutritional care. Running alongside these approaches is a need to tailor interventions to each patient’s physiological, psychological, and social circumstances. The purposes of intervention may differ depending on whether the patient is undergoing curative treatment, palliative treatment, or is in a position of survivorship post-curative treatment. The primary purpose of an eating intervention delivered to a patient with advanced cancer might be to improve the patient’s quality of life. In this circumstance, the nutritional balance of food intake might be less important than helping the patient to identify what he or she can eat [21]. For a colorectal cancer patient receiving treatment, the goal should be improvement in nutritional status [22], whereas for a breast cancer survivor, the goal is to support a healthy diet and lifestyle that reduces the risk for recurrence and other morbidity [23]. What is appropriate support will thus differ according to disease stage, cancer site, and whether or not the person is receiving treatment. Intervention choices also should take into account available social support and the implications of comorbidity. Actions required by nurses also may include overcoming barriers that may prevent patients receiving adequate food and drink [24], such as frailty. Eating well with cancer and support for eating well is not the same for all cancer patients. Information and advice Nutritional counseling can be described as the use of education informed by psychological theory to facilitate changes in eating behavior. Its importance for people with cancer is to encourage optimal dietary intake to minimize nutritional risk, while taking into account individual circumstances, such as food preferences. Tailoring advice to individual patient need is an essential part of the process of facilitating dietary change. Consideration should be given to use of theory-based approaches to behavioral change to communicate nutritional information
600
J. B. Hopkinson / Nutrition 31 (2015) 598–602
Table 1 Examples of nurse involvement in the nutritional support of older patients Author (y)
Description of study
Nutritional support provided by nurses
Impact on patient health outcomes
Young et al. (2011) [25].
Systematic review of nutritional intervention for community-dwelling older people: 23 RCTs (each recruiting from 22–2558 people age 65 y)
Nutritional education was provided solely by nurses in 10 of the studies either alone or as part of a complex intervention.
Baldwin and Weeks (2011) [26].
Systematic review of dietary advice with or without nutritional supplements in disease-related malnutrition: 45 RCTs (3186 participants)
Nutritional counseling was delivered by nurses in one study to participants mean age 60 [18].
Hopkinson et al. (2010) [27].
An exploratory trial of the MAWE, a psychosocial intervention that includes nutritional counseling: 25 advanced cancer patients, median age 69 y
Nurses delivered complex intervention that included a nutritional counseling component supported by information leaflets
Kennelly et al. (2010) [28].
Evaluation of an education program to improve the management of malnourished patients in the community: 82 nurse participants
Nurses used MUST and offered dietary advice
The review found that nutritional education or advice can improve physical function, improve diet and, as a component of a complex intervention, reduce depression. Nutritional education or advice provided by nurses was found to improve physical function and mental health/emotional well-being in 5 of 6 of the studies where these were measured outcomes. The review found dietary advice, with or without oral nutritional supplements may improve weight, body composition and grip strength. The study of nurse-delivered nutritional counseling found slower decline in performance status compared with a control group. Patients reported change in the type of foods eaten to those that were nutrition dense and easy to eat. They also increased the number of times they ate during the day. Nurses self-reported improved management of malnourished patients, for example, giving dietary advice more often.
MAWE, Macmillan Approach to Weight and Eating; MUST, Malnutrition Universal Screening Tool; RCT, randomized controlled trial.
(e.g., motivational interviewing, therapeutic story telling). Table 2 lists examples of advice nurses can offer patients in the context of nutritional counseling. (Note: The recommendations are based mainly on studies of malnourished older people, as cancer-specific studies have yet to be conducted). Involving family caregivers in nutritional care The MAWE (Macmillan Approach to Weight and Eating) studies research program carried out in the United Kingdom
found that family members influence the eating behaviors of patients with advanced cancer. In some cases, this influence was helpful. But in others, disagreements within the family about food and eating could be detrimental to both quality of life and the patient’s nutritional intake [29]. Typically, these disagreements were fueled by uncertainty about what best to do. Nurses may be able to reduce nutritional risk in cancer patients by offering supportive nutritional interventions not only to the patient, but also by involving their family caregiver. Raising family members’ awareness of potential barriers and obstacles to
Table 2 Advice nurses should consider offering cancer patients Try sip feeds and other supplements
Take regular foods that are nutritionally dense
Try high-protein oral nutritional supplements
Take supplements between meals Eat when most hungry (typically early morning) Eat energy- and protein-rich foods (e.g., full-fat dairy) Follow a diet that is easy to eat (i.e., soft and moist) Try cold foods (if the smell of food is a problem) Experiment with flavors (if taste is a problem) Try sipping fluid with food (if dry mouth is a problem) Try preprepared food (if fatigue is a problem) Misunderstandings can contribute to poor nutrition, such as the belief that hot foods are of greater nutritional value than cold
Supplements (protein and energy usually as sip feeds) produce a small but consistent weight gain in older people. Mortality may be reduced in older people who are malnourished [30]. Counseling with regular foods is of benefit in improving nutritional status, reducing treatment toxicity, and improving quality of life in patients with colorectal cancer treated with radiotherapy. [22]. The American Dietetic Association recommends that the quality of life and nutritional status of older adults residing in health care communities can be enhanced by individualization to less-restrictive diets tailored according to each person’s individual medical condition, needs, desires, and rights [31]. Systematic review involving 36 randomized controlled trials (N ¼ 3790; mean age 74 y) effects across settings and patient groups in favor of the high-protein oral nutritional supplements. These include reduced hospital readmissions; improved grip strength; increased intake of protein and energy with little reduction in normal food intake, and improvements in weight [32]. Expert opinion of author [33]. Recommendations for cancer patients with eating problems made by experts in professional journals [34]
Expert opinion of authors based on clinical and research practice [35].
J. B. Hopkinson / Nutrition 31 (2015) 598–602
receiving adequate food and drink could be an important role for nurses. Nurses should perhaps give family caregivers guidance on food choices, patient positioning, and appropriate assistance with feeding.
The need to improve nurse education in the provision of nutritional support Although it might be assumed that the provision of nutritional support to cancer patients has intuitively obvious benefits, this may not be so. For example, of 40 cancer patients recruited into a study in New Zealand, not one reported receiving dietary information from the doctor or nurse [36]. Similarly, studies on patients with advanced cancer in the United Kingdom have identified a culture of weight loss taboo that inhibited nutritional intervention [37] and inconsistent management of symptoms that can affect nutritional status [38]. In Austria, a survey of hospital patients (n ¼ 2326) and nursing homes residents (n ¼ 1487) found the prevalence of malnutrition was high but guidelines for its management were used infrequently, with a substantial number of patients or residents receiving no nutritional intervention [39]. Australian practice nurses have been found to recognize the importance of nutrition to chronic disease management but to be unsure of the effectiveness of the nutritional advice they give and to believe additional nutritional education would help them provide nutritional care [40]. A questionnaire survey conducted in Australia found only 39% (n ¼ 2759) of nurses to consider their basic nutritional education sufficient [41]. Similarly, nurses and student nurses in the United States recognized the importance of nutritional care but lacked knowledge in the nutritional management of diabetes and believed they would benefit from additional nutritional education [42]. In 2009, the British Association for Parenteral and Enteral Nutrition published a report that highlighted the need for education and training if patients are to receive appropriate nutritional care, support, and treatment [43]. There is evidence of a gap in the training of nurses, which suggests a lack of confidence and competence in offering nutritional support may explain their observed lack of engagement in delivering nutritional interventions. It has been noted that nutrition is included as only a small part of a broader nursing education [9]. Yet nutritional education can make a difference to the provision of supportive nutritional care. For example, evaluation of a training program for 16 hospital nurses found that after 12 mo they were more confident in nutritional management and exhibited a greater awareness of and responsibility for nurse-specific intervention [44].
Conclusion This article identified a number of ways in which nurses can contribute to the nutritional support of older cancer patients. Nurses must be able to recognize common indicators of nutrition risk and be able to tailor their support to the needs of individual patients. In the absence of such support, patients and their families may be uncertain as to how to approach eating issues. Such uncertainty is a potential cause of family disagreements and may increase the prevalence of the use of inappropriate advice from nonexperts. But, although there is much potential for nurses to contribute to the nutritional support of older cancer patients, there are also significant opportunities for the improvement of training and practice.
601
References [1] World Health Organisation 2013, Health topics: ageing. Available at: http:// www.who.int/topics/ageing/en/. Accessed January 9, 2015. [2] Cancer Research UK 2012, Cancer incidence by age. Available at: http://www. cancerresearchuk.org/cancer-info/cancerstats/incidence/age/. Accessed January 9, 2015. [3] Edwards BK, Howe HL, Ries LAG, Thun MJ, Rosenberg HM, Yancik R, et al. Annual report to the nation on the status of cancer 1973 to 1999, featuring implications of age and ageing on U.S. cancer burden. Cancer 2002;94:2766–92. [4] Stratton RJ, Green CJ, Elia M. Disease related malnutrition: an evidence based approach to treatment. Oxford: CABI Publishing; 2003. [5] British Dietetic Association. Malnutrition. In: Thomas B, Bishop J, editors. Manual of dietetic practice. Oxford, UK: Blackwell Publishing Limited; 2007. p. 80–90. [6] Ottery FD. Definition of standardized nutritional assessment and interventional pathways in oncology. Nutrition 1996;12(Suppl 1):S15–9. [7] Vellas B, Guigoz Y, Garry PJ, Nourhashemi F, Lauque S, Albarede JL. The Mini Nutritional Assessment (MNA) and its use in grading the nutritional state of elderly patients. Nutrition 1999;15:116–22. [8] Stratton RJ, Hackston A, Longmore D, Dixon R, Price S, Stroud M, et al. Malnutrition in hospital outpatients and inpatients: prevalence, concurrent validity and ease of use of the “malnutrition universal screening tool” (MUST) for adults. Br J Nutr 2004;92:799–808. [9] Henning M. Nursing’s role in nutrition. Comput Inform Nurs 2009;27:301–6. [10] World Health Organisation. Nutrition for older persons - keep fit for life. Meeting the nutritional needs of older persons. Available at: http:// www.who.int/nutrition/topics/ageing/en/index1.html. Accessed January 9, 2015. [11] Lazarus RS. Stress and emotion: a new synthesis. London: Free Association Press; 1999. [12] Muir CI, Linklater GT. A qualitative analysis of the nutritional requirements of palliative care patients. J Hum Nutr Diet 2011;24:470–8. [13] Hawkins C, Andrews I, Aston T, Beyer T, Cairns J, Hansford B, et al. Multidisciplinary approach to nutritional problems. In: del Fabbro E, Bruera E, Demark-Wahnefried W, Bowling T, Hopinson JB, Baracos VE, editors. Nutrition and the cancer patient. Oxford: Oxford University Press; 2010. p. 237–54. [14] Gosney M. General care of the older cancer patient. Clin Oncol 2009;21:86–91. [15] Hopkinson JB, Fenlon D, Nicholls P, Wright D, Okamoto I, Roffe L, et al. Helping people live with advanced cancer: an exploratory cluster randomised trial to investigate the effectiveness of the “Macmillan Approach to Weight loss and Eating difficulties: (MAWE)”. London: Macmillan Cancer Support; 2008. [16] Kennelly S, Kennedy NP, Corish CA, Flanagan-Rughoobur G, GlennonSlattery C, Sugrue S. Sustained benefits of a community dietetics intervention designed to improve oral nutritional supplement prescribing practices. J Hum Nutr Diet 2011;24:496–504. [17] Kim S, Shin MS, Lee HS, Lee ES, Ro JS, Kang HS, et al. Randomized pilot test of simultaneous exercise and diet intervention for breast cancer survivors. Oncol Nurs Forum 2011;38:E97–106. [18] Dixon J. Effect of nursing interventions on nutritional and performance status in cancer patients. Nursing Research 1984;33(6):330–5. [19] Lewin RJ, Furze G, Robinson J, Griffiths K, Wiseman S, Pye M, et al. A randomised controlled trial of a self-management plan for patients with newly diagnosed angina. Br J Gen Pract 2002;52:194–6. 199–201. [20] Thompson RL, Summerbell CD, Hooper L, Higgins JPT, Little P, Talbot D, et al. Dietary advice given by a dietitian versus other health professional or self-help resources to reduce blood cholesterol. Cochrane Database Syst Rev; 2003:CD001366. [21] Hopkinson JB, Okamoto I, Addington-Hall J. What to eat when off treatment and living with involuntary weight loss and cancer: a systematic search and narrative review. Support Care Cancer 2011;19:1–17. [22] Ravasco P, Monteiro-Grillo P, Camila M. Individualized nutrition intervention is of major benefit to colorectal cancer patients: long-term follow-up of a randomized controlled trial of nutritional therapy. Am J Clin Nutr 2012;96:1346–53. [23] Demark-Wahnefried W, Clipp EC, Lipkus IM, Lobach D, Snyder DC, Sloane R, et al. Main outcomes of the FRESH START trial: a sequentially tailored, diet and exercise mailed print intervention among breast and prostate cancer survivors. J Clin Oncol 2007;25:2709–18. [24] Bloomfield J, Pengram A. Improving nutrition and hydration in hospital: the nurses’ responsibility. Nurs Stand 2012;26:52–6. [25] Young K, Bunn F, Trivedi D, Dickinson A. Nutritional education for community dwelling older people: a systematic review of randomised controlled trials. Int J Nurs Stud 2011;48:751–80. [26] Baldwin C, Weeks CE. Dietary advice with or without oral nutritional supplements for disease-related malnutrition in adults. Cochrane Database Syst Rev; 2011:CD002008. [27] Hopkinson JB, Fenlon DR, Okamoto I, Wright DNM, Scott I, AddingtonHall J, et al. The Macmillan Approach to Weight loss and Eating difficulties
602
[28]
[29] [30]
[31]
[32]
[33] [34] [35]
J. B. Hopkinson / Nutrition 31 (2015) 598–602 (MAWE): a phase II cluster randomised exploratory trial of a psychosocial intervention for weight and eating related distress in people with advanced cancer. J Pain Symptom Manage 2010;40:684–95. Kennelly S, Kennedy NP, Rughoobur GF, Slattery CG, Sugrue S. An evaluation of a community dietetics intervention on the management of malnutrition for healthcare professionals. J Hum Nutr Diet 2010;23:567–74. Hopkinson JB. Caregivers’ influence on diets of people with advanced cancer. Nurs Times 2008;104:28–9. Milne AC, Potter J, Vivanti A, Aveneli A. Protein and energy supplementation in elderly people at risk from malnutrition. Cochrane Database Syst Rev; 2009:CD003288. American Dietetic Association. Practice paper of the American Dietetic Association: individualized nutrition approaches for older adults in health care communities. J Am Diet Assoc 2010;110:1554–62. Cawood AL, Elia M, Stratton RJ. Systematic review and meta-analysis of the effects of high protein oral nutritional supplements. Ageing Res Rev 2011;11:278–96. Morley JE. Calories and cachexia. Curr Opin Clin Nutr Metab Care 2009;12:607–10. Hopkinson JB. Change in eating habits. In: Corner J, Bailey C, editors. Cancer nursing: care in context. Victoria: Blackwell; 2008. p. 525–32. Hopkinson JB, Strasser F. Psychosocial aspects of nutrition. In: van Halteren H, Jatoi A, editors. Nutrition and cancer. Viganello-Lugano, Switzerland: ESMO Press; 2011. p. 73–80.
[36] Pullar J, Chisholm A, Jackson C. Dietary information for colorectal cancer survivors: an unmet need. N Z Med J 2012;125:27–37. [37] Hopkinson JB, Wright DNM, Corner JL. The experience of weight loss in people with advanced cancer. J Adv Nurs 2006;54:304–12. [38] Churm D, Andrew I, Holden K, Hawkins C. A questionnaire study of the approach to anorexia-cachexia syndrome in patients with cancer by staff in a district general hospital. Support Care Cancer 2009;17:503–7. [39] Schonherr S, Halfens RJG, Meijer JMM, Schols JMGA, Lohrmann C. Structural and process indicators of nutritional care: a comparison between Austrian hospitals and nursing homes. Nutrition 2012;28:868–73. [40] Martin L, Leveritt MD, Desbrow B, Ball LE. The self-perceived knowledge, skills and attitudes of Australian practice nurses in providing nutrition care to patients with chronic disease. Fam Pract 2014;31:201–8. [41] Johansson U, Rasmussen HH, Mowe M, Staun M, Scandinavian Nutrition Group. Clinical nutrition in medical gastroenterology: room for improvement. Clin Nutr 2009;28:129–33. [42] Carney T, Stein SE, Quinlan JJ. The need of additional training for nutritional management of diabetes. Br J Nurs 2013;22:512. 514–7. [43] Elia M, Smith RM, Improving nutritional care and treatment Perspectives and Recommendations from Population Groups, Patients and Carers. A report from BAPEN. 2009. [44] Bjerrum M, Tewes M, Pedersen P. Nurses’ self-reported knowledge about and attitude to nutritiondbefore and after a training programme. Scand J Caring Sci 2011;26:81–9.