Physical Assessment and Management of Protein Calorie Malnutrition in Hospice Care

Initial Assessment Components

The American College of Physicians recommends conducting 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
A general clinical assessment should include 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) is recommended 3, 1
Assessment of body composition and muscle mass/strength is also necessary 3, 2

Measuring weight and height to calculate BMI, correcting for fluid retention when applicable, is a recommended approach 1, 4
Assessing handgrip strength as a functional measure of nutritional status is suggested 1
Measuring mid-upper arm circumference and derived midarm muscle circumference to evaluate muscle mass is recommended 4
Documenting functional status using validated scales such as WHO or Karnofsky scale is necessary 1

Serum proteins assessment including albumin and pre-albumin (noting these are also affected by inflammation) is recommended 3, 4
Checking inflammatory markers like C-reactive protein to correctly interpret albumin levels is suggested 4

Monitoring dietary intake for several days (e.g., using plate diagrams) to estimate food and fluid consumed is recommended 5, 2
Comparing actual intake to estimated requirements (at least 1.0 g/kg protein should be ensured in older persons) is necessary 5
Assessing for appetite loss, which has high prognostic power in predicting malnutrition risk, is suggested 6

Focusing interventions on comfort and quality of life rather than aggressive nutritional repletion is recommended 1, 7
Offering mealtime assistance for patients with eating dependency to support adequate intake for comfort is suggested 2
Encouraging sharing mealtimes with others to improve quality of life and stimulate intake when appropriate is recommended 2
Considering oral nutritional supplements only if they enhance comfort and are tolerated is necessary 1

Regularly reassessing nutritional status and adjusting interventions according to the patient's changing condition is recommended 2
Coordinating nutritional care with the interdisciplinary team (medical specialists, nurses, therapists) is necessary 2
Maintaining intensive communication with the patient and family regarding wishes and expectations throughout the process is suggested 2

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
Ensuring comprehensive assessment before determining PCM as the primary hospice diagnosis is necessary 1