Pain May Lead to Malnutrition in Nursing Home Patients

      Pain may be a factor in malnutrition in nursing home residents, according to a recent study published in Clinical Nutrition. The report points to a need for prompt assessment and treatment of pain to prevent appetite loss in this population, and consideration of the nutritional impact of drugs when selecting analgesics.
      In an analysis of data on individuals in 12 nursing homes, Austrian researchers looked at relationships between pain, appetite, and other factors that may have influenced malnutrition. The population assessed, in a secondary analysis from the OSiA (Optimiertes Schmerzmanagement in Altenpflegeheimen, or “optimized pain management in nursing homes”) Study, was 243 nursing home residents 60 or older who had mild or no cognitive impairment (Clin Nutr 2015;34[Suppl 1]:557).
      Baseline information was drawn from standardized questionnaires and medical documentation. Pain was detected with a verbal rating scale, and a Simplified Nutritional Appetite Questionnaire (SNAQ) was used to detect risk of malnutrition in the patients. A SNAQ score of at least 14 indicates that an individual is at risk of weight loss of at least 5% in the next 6 months.
      Cross-sectional and single-case analyses showed that overall, 66% of the nursing home residents had pain at rest or in action, 22% had no appetite because of pain, and 25% were at risk of malnourishment. Of the patients in the latter group, 30% reported pain. Pain was reported as the cause of loss of appetite by 43% of those who were at risk for both malnutrition and pain.
      Looking at use of analgesics in the population, the authors found that 64% of patients at risk of malnutrition, pain, and pain-associated loss of appetite were given analgesics with known adverse effects that included appetite loss, nausea, and vomiting. The drugs in this “inadequate” category that were most commonly prescribed were oral hydromorphone and transdermal fentanyl, and they were given in higher quantity than other drugs.
      The diagnoses that triggered use of analgesics in the study population included disorders of spine/extremities, injuries, arthrosis, and gastritis/gastralgia, and did not differ whether treatment was considered adequate or inadequate. There were also no differences in use of additional analgesics, such as local diclofenac and oral metamizol (also known as dipyrone, a non-NSAID analgesic and antipyretic not available in the United States), in patients on hydromorphone or fentanyl vs. other pain medications.
      Presenting the results at the 37th Congress of the European Society for Clinical Nutrition and Metabolism in Lisbon, Portugal, Maria Magdalena Schreier of the Institut of Nursing Science and Practice at Paracelsus Medical University said that screening and assessment of malnutrition should consider pain as a favoring factor for poor appetite. “Nearly two-thirds of the selected residents received analgesics with nutritional side effects. Those analgesics may play an important role in the context of malnutrition.” She encouraged clinicians caring for nursing home residents to assess them for pain systematically and to provide adequate pain treatment to prevent malnourishment in these patients. The appetite-reducing potential of drugs, too, should be considered.
      Judith M. Orvos, ELS, is a freelance medical writer and president of Orvos Communications in Washington, DC.

      PA/LTC Perspective

      In this study, 243 residents 60 years or older with no or mild cognitive impairment from 12 nursing homes were screened for pain and assessed for appetite using SNAQ (Short Nutritional Assessment Questionnaire). The results of this study indicated that pain was reported as the cause of loss of appetite by 43% of residents at risk for both malnutrition and pain. Additionally, the researchers investigated the use of analgesics in this population and reported that some of the medications used for pain — oral hydromorphone and fentanyl patches — caused side effects including appetite loss, nausea, and vomiting. The researchers concluded that pain should be evaluated for all nursing home residents using a systematic pain assessment tool and that analgesics provided should be considered for potential nutritional side effects.
      This study validates and quantifies the impact of pain as a risk factor for malnutrition in older adults in long-term care. In addition to other physical causes of malnutrition including impaired oral status, physical limitations, chronic disease, early satiety, and changes in taste and smell, the presence of pain should be considered when evaluating a resident's risk for malnutrition. Although medications can be helpful to control pain, there are potential side effects of medications which can have negative impacts on nutrition status, including loss of appetite, nausea, vomiting, and constipation, among others. An interdisciplinary approach including the physician, registered nurse, and dietitian should be considered when evaluating and treating pain in the institutionalized older adult.
      —Phyllis Famularo, DCN, RD
      Senior Manager, Nutrition Services, Sodexo