Polymorbidity
Polymorbidity affects approximately 70% of hospitalized patients and is defined as the simultaneous presence of at least two chronic conditions in the same person 1, 2. Polymorbidity is often, but not necessarily, observed in older individuals. With increasing life expectancy, the rise in chronic illnesses, and advances in medical care, polymorbidity is becoming one of the primary challenges faced by health and social care systems worldwide. Polymorbidity is associated with higher mortality, morbidity, functional decline, impaired quality of life, and increased healthcare costs 2-4. Furthermore, the risk of malnutrition increases with the number of chronic conditions 5, 6.
To date, clinical guidelines for nutrition have primarily focused on specific medical conditions or groups of patients, making their application to complex patients with various conditions challenging. Fried et al. demonstrated that clinicians could benefit from overarching recommendations that support their decision-making 7. Although this issue has not been fully addressed, recent large studies have shown that nutritional therapy can effectively reduce morbidity, complications, and mortality in polymorbid patients and improve their quality of life 5, 6.
Nutrient requirements of polymorbid patients. Adjustments are necessary for malnourished patients, physical activity, and patient age. The weight used is the adjusted body weight (ADJ) starting from a BMI of 28; otherwise, the body weight prior to hospital admission applies 3. BW = body weight; d = day; bHMB = beta-hydroxy-beta-methylbutyrate; EN = enteral nutrition.
Please fill out the weight
Vitamins, Minerals, and Trace Elements
- Coverage of daily requirements
- Substitution for proven or suspected deficiencies
Aims of Nutritional Therapy
- Maintaining/improving nutritional status and body function
- Avoiding malnutrition/nutrient deficits
- Preserving muscle mass and functionality
- Improving quality of life
- Reducing mortality, complication rates, and hospital readmissions
To identify malnourished patients at an early stage, screening for malnutrition should be performed using a validated tool, such as the Nutritional Risk Screening (NRS), within 48 hours of hospital admission.
Energy and protein requirements should be met through oral nutrition whenever possible. If less than 75% of requirements are met even with fortification, snacks, or oral nutritional supplements (ONS), supplementary enteral nutrition should be initiated. Parenteral nutrition is indicated if less than 75% of requirements are met through oral and/or enteral nutrition.
Oral Nutrition
For malnourished, polymorbid patients or those at high risk of malnutrition who can be fed orally, early individualized nutritional therapy through oral nutritional supplements (ONS) should be offered to cost-effectively improve their nutritional status, quality of life, and overall survival. Food fortification can also be considered an effective measure, either alongside or instead of ONS, to achieve the appropriate energy and protein targets and improve nutrient intake. 8
Enteral and Parenteral Nutrition
For patients requiring enteral nutrition, products containing both soluble and insoluble fibers should be used to improve bowel function. Enteral nutrition is superior to parenteral nutrition due to its lower risk of infectious and non-infectious complications and its role in maintaining intestinal integrity. 8
Monitoring
Nutritional and functional parameters should be monitored to evaluate the response to nutritional therapy. One parameter with prognostic potential is handgrip strength. 8
Special Considerations
Nutritional therapy should be continued after hospital discharge to maintain or improve body weight, nutritional status, functional status, and quality of life. For individuals over 65 years of age, this support should continue for more than two months. 8
Medications/Supplements
Polymorbidity is always associated with polypharmacy, placing polymorbid patients at significant risk for interactions between drugs and also between drugs and nutrients. Therefore, it is essential to establish a management plan for such interactions, involving a pharmacist. 8
- Lefevre, T., et al., What do we mean by multimorbidity? An analysis of the literature on multimorbidity measures, associated factors, and impact on health services organization. Rev Epidemiol Sante Publique, 2014. 62(5): p. 305-14.
- Marengoni, A., et al., Aging with multimorbidity: a systematic review of the literature. Ageing Res Rev, 2011. 10(4): p. 430-9.
- Charlson, M.E., et al., Charlson Comorbidity Index: A Critical Review of Clinimetric Properties. Psychother Psychosom, 2022. 91(1): p. 8-35.
- Huntley, A.L., et al., Measures of multimorbidity and morbidity burden for use in primary care and community settings: a systematic review and guide. Ann Fam Med, 2012. 10(2): p. 134-41.
- Schuetz, P., et al., Individualised nutritional support in medical inpatients at nutritional risk: a randomised clinical trial. Lancet, 2019. 393(10188): p. 2312-2321.
- Deutz, N.E., et al., Readmission and mortality in malnourished, older, hospitalized adults treated with a specialized oral nutritional supplement: A randomized clinical trial. Clin Nutr, 2016. 35(1): p. 18-26.
- Fried, T.R., M.E. Tinetti, and L. Iannone, Primary care clinicians' experiences with treatment decision making for older persons with multiple conditions. Archives of Internal Medicine, 2011. 171(1): p. 75-80.
- Wunderle, C., et al., ESPEN guideline on nutritional support for polymorbid medical inpatients. Clin Nutr, 2023. 42(9): p. 1545-1568.
- Gomes, F., et al., ESPEN guidelines on nutritional support for polymorbid internal medicine patients. Clin Nutr, 2018. 37(1): p. 336-353
- Kaegi-Braun, N., et al., Six-month outcomes after individualized nutritional support during the hospital stay in medical patients at nutritional risk: Secondary analysis of a prospective randomized trial. Clin Nutr, 2021. 40(3): p. 812-819.
- Schuetz, P., et al., Economic evaluation of individualized nutritional support in medical inpatients: Secondary analysis of the EFFORT trial. Clin Nutr, 2020. 39(11): p. 3361-3368.
- Volkert, D., et al., ESPEN practical guideline: Clinical nutrition and hydration in geriatrics. Clin Nutr, 2022. 41(4): p. 958-989.
Authorship:
Carla Wunderle, PhD, Ernährungswissenschaftlerin, Kantonsspital Aarau
