Malnutrition Management: A Clinical Pathway Model for Symptom Management


Journal of Clinical Pathways. 2017;3(5):41-46.


1Department of Family Medicine, Prince George’s Hospital, Cheverly, MD;
2The Access Group, Berkeley Heights, NJ.


Dr Richard G Stefanacci

400 Connell Drive, 2nd Floor

Berkeley Heights, NJ 07922

Phone: (908) 508-6714



Dr Stefanacci is the chief medical officer for The Access Group, a managed markets agency for pharmaceutical companies. The other authors report no relevant financial relationships.

Abstract: Although clinical pathways are most often developed for very narrow diagnoses with limited pharmaceutical treatments, they are even more needed to provide direction for symptom management involving multiple diagnoses, with myriad pharmaceutical and nonpharmaceutical treatments—such as malnutrition management. A clinical pathway model for malnutrition management can be applied across many systems, such as in long-term care facilities and integrated delivery systems. Its application within these health systems offer the best opportunities for improved clinical and economic outcomes.

Received January 4, 2017

Accepted May 17, 2017

Involuntary weight loss as a result of malnutrition is a major problem among elderly patients residing in long-term care facilities (LTCFs). Malnutrition is defined as a deficiency of calorie, protein, or other nutrients that result in adverse outcomes on body function, body form, or clinical outcome.1 Estimates of malnutrition prevalence in the LTCFs range from 1.5% to 66.5%, due to variable assessment methods.2  Various parameters and cutoff values are used for nutritional assessment, with no expert consensus agreement.3 The Joint Commission requires screening for malnutrition of hospitalized patients,4 and federal guidelines recommend nursing homes reassess patient nutritional status given an unplanned weight loss of 5% or more in 1 month, 7.5% or more in 3 months, or 10% or more in 6 months.5 However, there is no mandate recommending a standardized screening tool, anthropometric assessment, or biochemical markers.

Malnutrition prevalence may have a direct impact on the risk adjustment of LTCFs outcome indicators, health care resource utilization, and financial outcomes for facilities. Elderly patients with malnutrition have been shown to experience more hospitalizations, longer lengths of stay, and higher cost of care.6 LTCFs may properly adjust outcome indicators based on malnutrition prevalence. For example, the elderly malnourished patient is more likely to develop pressure ulcers,6 which is an outcome indicator. Accurately documenting malnutrition may account for differences in the risk for adverse outcomes, which have financial implications to LTCFs.7 Accurate prevention and diagnoses of malnutrition is important for patient outcomes and LTCFs resource utilization.

Risk Factors for Malnutrition

Risk factors for malnutrition in the elderly can be broadly categorized into three main types: medical, social, and psychological.8 Aging does not lead to malnutrition, but the changes associated with aging can increase the risk for malnutrition, as presented in Table 1.9 Many chronic diseases contribute to inflammation that can lead to significant loss of muscle mass and malnutrition.10 Restrictive meal plans such as low salt, diabetic, and low cholesterol diets have also been shown to contribute to malnutrition in the elderly.11 

A recent systematic review of the literature found the significant risk factors for malnutrition in the elderly included age; frailty in institutionalized persons; excessive polypharmacy; general health decline, including physical function; Parkinson disease; constipation; poor or moderate self-reported health status; cognitive decline; dementia; eating dependencies; loss of interest in life; poor appetite; basal oral dysphagia; signs of impaired efficacy of swallowing; and institutionalization.12

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