Kennedy Williams

Scenario- 83 year-old resident of a skilled nursing facility presents to the emergency department with generalized edema of extremities and abdomen. History obtained from staff reveals the patient has history of malabsorption syndrome and difficulty eating due to lack of dentures. The patient has been diagnosed with protein malnutrition. Protein malnutrition, also known as protein-energy malnutrition (PEM), is an imbalance between nutrient requirements and intake, resulting in energy, protein, and micronutrient deficiencies (McCance & Huether, 2019). The most common types of PEM are Kwashiorkor and Marasmus. While this condition is common globally, it is predominant in developing countries and economically destitute populations (McCance & Huether, 2019). Protein-energy malnutrition is also a complication of chronic diseases such as malabsorption disorders, cardiac, renal, pulmonary, and neurological diseases, burns, anorexia, bulimia, and psychogenic illnesses (McCance & Huether, 2019). Genetics play a major role in the development of protein malnutrition. Genetics, such as age, family history, gender, influence the risk of acquiring protein malnutrition. Certain populations are more at risk including poor and low income, children, elderly, and chronically ill (Cleveland Clinic, 2022). Elderly are at a greater risk for malnutrition for several reasons including decreased mobility, institutionalization, reduced appetite, reduced absorption of nutrients (Cleveland Clinic, 2022). The 83-year-old patient has been diagnosed with protein malnutrition, in which is influenced greatly by genetics. The patient’s medical history of malabsorption syndrome, which is caused by diseases, infections, or development issues, plays an important part in the development of protein malnutrition. Malabsorption syndrome causes a decrease in the number of nutrients and fluids absorbed by the small intestine. Ulrich Keller stated that albumin is the most abundant protein and is an indicator of malnutrition in patients (2019). Albumin is a protein made in the liver and helps keep fluid from leaking out of vessels, therefore maintaining oncotic pressure. Reduced levels of albumin in the blood lead to protein malnutrition. A clear relationship between serum albumin concentrations and all cause mortality in elderly subjects has been identified (Keller, 2019). The patient’s age increased her risk for developing protein malnutrition. If the patient was younger, the chance of her developing protein malnutrition would be decreased. Elderly individuals have an increased risk for reduced absorption of nutrients and reduced appetite. The patients malabsorption syndrome and difficulty eating due to dentures further increased the risk of developing protein malnutrition. If the patient was younger, the body would absorb more nutrients than an elderly individual even with malabsorption syndrome. Also, if the patient was younger there would be a decreased chance the patient would have difficulty eating due to dentures leading to an increase in nutrient and fluid intake. In this case study, the patient presents with generalized edema of extremities and abdomen. Generalized edema affects the entire body. Albumin, the most abundant protein, maintains oncotic pressure, maintaining fluid within the interstitial and capillary space. The lack of albumin causes an imbalance between hydrostatic and oncotic capillary pressures. This imbalance leads to fluid and sodium leaving the capillary’s and entering the interstitial space, causing edema. The lack of protein leads to generalized edema and a substantial loss of potassium (McCance & Huether, 2019). Metabolic imbalances of intracellular accumulations lead to sub-lethal cellular injury and inadequate cell functioning (McCance & Huether, 2019). The main cells involved in this process are immune cells, including tumor necrosis factor-alpha, interleukin-6, T-cells, and Leptin (Alwarawrah et al., 2018). Immune cells reside in adipose tissue and are affected by changes and in turn contribute to altered immune cell production in states of under-nutrition (Alwarawrah et al., 2018). Therefore, alterations in cellular metabolism influence immune cell function (Alwarawrah et al., 2018). Under-nutrition leads to a decrease in immune cell function leading to an increased risk for infections and illnesses.