Effective provision of comprehensive nutrition case management for the elderly

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Effective provision of comprehensive nutrition case management for the elderly SUSAN SAFFEL-SHREIR, MS, RD; BONNIE M. ATHAS, RD

AIITIUC: In response to the Nutrition Screening Initiative, we have outlined a new role for the registered dietitian (RD) in effectively providing comprehensive nutrition case management using a functional approach to nutritional status assessment of the elderly. Recommendations are provided for coordinating access to resources. We propose that through this method RDs will be seen as essential members of the health care team who will provide intervention through direct assistance with the patients. Practical steps and assessment instruments specifically designed for RDs are provided that may be incorporated into routine nutrition screening, assessment, and case management within the health care delivery practice. JAm Diet Assoc. 1993; 93:439-444.

ealth care systems have not effectively incorporated routine nutrition screening, assessment, intervention, and case management into the delivery of services. Health programs are just beginning to recognize that the provision and maintenance of adequate nutrition can reduce health care cost and improve quality of life. Many of America's elderly are documented to be at nutritional risk because of their life-styles, functional ability, and physical and mental health status (1-3). The Nutrition Screening Initiative (NSI) has reported that 24% of the elderly are at high nutritional risk and 38% are at moderate nutritional risk (4,5). Patients whose nutritional status is adequate have better health outcomes. Conversely, patients with a compromised nutritional status have three times the number of major complications, stay in the hospital two thirds longer, incur several thousand dollars more in charges per hospital stay, and are three times more likely to die (6). The 1988 Surgeon General's Workshop on Health Promotion and Aging recommended that a nutrition assessment be completed on all older patients admitted to health care institutions or communitybased health services (7). This is an opportune time for registered dietitians (RDs) to take a leading role in effectively educating the health care team about the importance of nutrition assessment in combination with case management in health promotion and disease prevention. Through nutrition assessment/case management, the true effect of maintaining or restoring nutritional status can be documented and a comprehensive nutrition case management (CNCM) service is developed. Who on the health care team is better educated and qualified to provide CNCM than the RD? Yet if RDs are to be recognized S. Saffel-Shrier is an instructorin the Division of GeriatricMedicine, Department of Family and Preventive Medicine, University of Utah School of Medicine, Salt Lake City, UT 84132, B. M Athas is a consultant in the areas of nutrition,senior centers, and healthfor the State Division ofAging and Adult Services, Department of Human Services, Salt Lake City, UT 84103. JOURNAL OF THE AMERICAN DIETETIC ASSOCIATION / 439

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as the providers of CNCM, they will need to take responsibility for examining the processes for routine nutrition services in both the clinical and community setting. CNCM for the elderly is the process of assessing, planning, arranging, coordinating, and monitoring service delivery for patients at nutritional risk to ensure the delivery of appropriate, high-quality nutrition services in a timely and cost-effective manner. Nutrition case management is a series of activities that integrate nutrition screening/assessment findings with multiple health and community services for patients. Nutrition case management is a vehicle to ensure that elderly patients have appropriate access to the continuum of health care. THE RD'S ROLE IN NUTRITION CASE MANAGEMENT RDs must make themselves known and accessible to other health care providers. They must become well acquainted with organizations and service delivery systems that play important roles in nutrition case management. The elderly population is at disproportionate risk of malnutrition. The elderly also tend to be more involved with the health care system than other age groups. By understanding current and future demographic trends, RDs can develop plans for CNCM that include initial screening/assessment as well as care plans and goals. Then, RDs can project patient loads and required services in their communities and take the lead for quality CNCM progams. In almost all areas of their expertise, RDs will encounter the elderly population. Within their practice they should incorporate: * coordinated support for dietitians, nutritionists, and others who play key roles in implementing nutrition screening and intervention programs; * communication of nutrition status to physicians, nurses, and other medical and allied health professionals; * education to outreach workers of aging services, discharge planners of nursing facilities and hospitals, and third-party payers; and * orchestration of nutritional information to policymakers, the public, the elderly, and family and caregivers. Various nutrition screening and assessment instruments that correctly direct a plan of care for nutrition intervention are primary to the CNCM process. These instruments, used by professionals and lay persons, can originate in numerous settings such as state and local aging services, health departments, community adult education services, and various professional entities. Effective screening instruments will ensure improved coordination of community services. NSI has devised an excellent first-step screening instrument, "DETERMINE Your Nutritional Risk," as well as a Level 1 and 2 screen that identifies major and minor indicators of poor nutritional status (8). RDs should be actively involved in the referral process for those elderly found to be at moderate nutritional risk and should perform nutritional status assessment on those elderly at high nutritional risk. CNCM should identify the indicators of poor nutritional status through screening. Nutrition assessment is more than treating signs and symptoms. CNCM for the elderly should be coordinated by an RD. MAINTAINING OR INCREASING FUNCTION IS THE GOAL OF CARE In preparing to collect detailed nutritional status information, the RD, like other professionals practicing in the area of gerontology/geriatrics, must deemphasize the classic signs and symptoms of disease presentation and understand that the common pathway of many disorders in older persons is a restricted ability to function independently. Functional impair440 / APRIL 1993 VOLUME 93 NUMBER 4

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ment is the decreased ability to meet one's own needs. Along with problems with mobility, cognition, and continence, poor nutrition is frequently one of the first manifestations of disease in older persons. Therefore, the RD not only must address the immediate warning signs of poor nutritional health, but must also be aware of a potential undiagnosed disease. Maintaining or increasing function should be the goal of care. FUNCTIONAL ASSESSMENT AS PART OF ROUTINE SCREENING AND ASSESSMENT Identification of a patient's specific obstacles to independent living via functional assessment can lead to improved nutritional status and less costly, more agreeable alternatives to care. Functional assessment, routinely used by health professionals in the aging field, can be accomplished by the evaluation of Activities of Daily Living, which refer to basic self-care activities (bathing, dressing, toileting, transferring [helping move from bed to chair, car, and so on], continence, and feeding), and Instrumental Activities of Daily Living, which encompass more complex tasks of daily living (ability to use the telephone, shopping, food preparation, housekeeping, laundry, mode of transportation, responsibility for own medication, and ability to handle finances) (9,10). Functional assessment of the elderly is imperative in improving diagnostic and therapeutic outcomes and critical in predicting admissions to nursing homes, use of paid home care, use of hospital services, and mortality (11-13). Functional assessment provides data that influence every aspect of providing adequate nutrition, prevention or delay of disease, and an overall reduction in health care costs. Although functional assessment may not appear to be related to nutritional adequacy, the instrument may be adapted to provide RDs with a better understanding of an older person's life-style and nutritional status. Functional assessment can help the RD identify biological and psychosocial issues impeding acquisition of adequate nutrition (Figure 1). FUNCTIONAL ASSESSMENT FACILITATES INTERDISCIPLINARY EDUCATION AND IMPROVES HEALTH CARE Incorporation of the functional assessment instrument into CNCM also provides an essential common ground of communication between multidisciplinary team members. When all health care team members understand the principles and terminology behind functional assessment, the lines of communication are opened and dialogue is stimulated. In this way, interdisciplinary education can occur and can facilitate improved health care for the older person. It must be understood that the health care team does not necessarily have to be housed in one facility, nor does it have to consist solely of the traditional membership of physician, nurse, social worker, pharmacist, and dietitian. The team should be community-based and should include family members, caregivers, home health aides, or anyone involved in the care of the older person. Meeting to discuss health and nutrition issues via a follow-up visit or a family consultation, the team can have a better understanding of the problems of the older person. The success in the provision of excellent care to the older person depends on a cohesive team that can communicate well. OTHER COMPONENTS OF CNCM When appropriate screening reveals that a patient is at high nutritional risk, nutrition information beyond the functional assessment should be collected. This includes a dietary history, physical data, biochemical data, and a medication history. This

FIG 1. Fbrrnforassessing social andfunctionalcapability.

detailed information is typically gathered in the medical setting and can assist in determining diagnoses, setting goals, and directing care plans. Obtaining an accurate dietary history can be challenging, and RDs must be flexible in the pursuit of this information. RDs must take into consideration the patient's functional assessment data when determining the appropriate diet history method. A patient who is functionally independent but has a minor memory impairment should complete a record as meals are eaten. If a patient has dementia, a recall from a caregiver or a record from the dietary staff at the facility in which the patient resides can be completed (Figure 2). The physical data

needed in a CNCM must include common nutrition-related findings among older persons. NSI screening instruments can be used as major and minor indicators of poor nutritional status as a framework. Assessment questions should address the involvement of glossitis, xerostomia, fissures, muscle/bone pain, constipation, diarrhea, hydration, and weight loss. Unintentional weight loss of 10% or more over a 6-month period is supportive evidence of malnutrition. Any of these signs and symptoms warrants further investigation (Figure 3). The biochemical parameters used in assessing older persons are not notably different from those used for the younger population. However, some indexes have been adjusted for age JOURNAL OF THE AMERICAN DIETETIC ASSOCIATION / 441

PEIRPECTIVES I PIACTICE

FIG 2. Dietary intakeformforgeriatricassessmentfor nutrition case management.

(Figure 4). Serum albumin is one of the most readily available laboratory data to assess protein status, and it can complement a history of unintentional weight loss in the diagnosis of malnutrition. Normal hemoglobin levels for older persons should be -120 g/L in women and 140 g/L in men.' For the evaluation of anemia, a level of 120 g/L should be the lower limit of normal for both men and women (14). The measurement of serum cholesterol not only can be used in the diagnosis and treatment of coronary heart disease (levels >6.21 mmol/ L2), but also used in the diagnosis of malnutrition. A serum cholesterol <4.15 mmol/L is indicative of malnutrition (8,15). Levels of red blood cell folate and vitamin B-12 must be determined for patients that are confused or demented to rule

'To convert g/L hemoglobin to g/dL, multiply g/L by 0.1. To convert g/ dL hemoglobin to g/L, multiply g/dL by 10. 2 To convert mmol/L cholesterol to mg/dL, multiply mmol/L by 38.7. To convert mg/dL cholesterol to mmol/L, multiply mg/dL by 0.026. Cholesterol of 5.00 mmol/L = 193 mg/dL. 442 / APRIL 1993 VOLUME 93 NUMBER 4

out their possible involvement. A medication history, as part of the geriatric nutrition assessment, is imperative. The elderly typically take multiple medications; as a group they are the single largest users of medications. Drug/nutrient interactions and the effects of medication and dosage on functional status should be evaluated. INTEGRATED FUNCTIONAL DEFICITS WITH OTHER TEAM FINDINGS Of extreme importance is the summation of the findings of the nutrition assessment leading to nutrition case management. The patient's functional deficits should be integrated with the other team findings. Goals should be formulated to alleviate functional deficits. A goal is a generalized statement, eg, "Mrs X will be able to shop for food in 1 month." The care plan is the delineation of specific actions that will be coordinated or personally carried out to ensure that goals are met. Information from the Continuum of Care for Nutrition Case Management (Figure 5) can assist in ensuring continued dietary intake for the older person. When these last summary tasks are per-

FIG 3. Formfor assessingmedications, mental and physical status.

FIG 4. Necessary laboratorydata and diet historyfor nutritionalassessment of the older person.

JOURNAL OF THE AMERICAN DIETETIC ASSOCIATION / 443

FIG 5. Fobrm to help coordinatecomprehensive community services.

formed, the appropriate services can be contacted, the team will better understand the importance of the RD as a team member, and successful intervention can occur. CONCLUSION The stage is set to stress the importance of nutrition in health care delivery. The RD should advocate nutrition screening, assessment, and case management as the way to provide comprehensive nutrition services. At this time of heightened public and professional awareness of the health care crisis, the RD should be promoting and directing nutrition strategies and emphasizing the role of nutrition in health maintenance and disease prevention to help reduce the economic burden of the health care system. References 1. Bianchetti A, Rozzini R, Carabellese C, Zanetti O, Trabucchi M. Nutritional intake, socioeconomic conditions, and health status in a large elderly population. JAm GeriatrSoc. 1990; 38:521-526. 2. Kaiser FE. Principles of geriatric care. Am JKidney Dis. 1990; 16: 354-359. 3. White JV. Risk factors for poor nutritional status in older Americans. Am Fam Physician. 1991; 12:2087-2097. 4. Stevens DA, Grivetti LE, McDonald RB. Nutrient intake of urban and rural elderly receiving home-delivered meals. J Am Diet Assoc. 1992; 92:714-718. 5. Dwyer JT. Screening Older Americans' Nutritional Health444 / APRIL 1993 VOLUME 93 NUMBER 4

Current Practicesand Future Possibilities.Washington, DC: Nutri-

tien Screening Initiative; 1991. 6. Reilly JJ, Hull SF, Albert N, Waller A, Bringardener S. Economic impact of malnutrition: a model system for hospitalized patients. JPEN 1988; 12:371-376. 7. Surgeon General's Workshop: Health Promotion and Aging. Washington, DC: US Dept of Health and Human Services, Public Health Service; 1988. 8. Nutrition Screening I: Nutrition Screening ManualforProfessionals Caring for Older Americans. Washington, DC: Nutrition Screening Initiative; 1991. 9. Katz S, Downs TD, Cash HR. Progress in the development of the index of ADL. Gerontologist.1970; 10:20-30. 10. Lawton MP, Brody EM. Assessment of older people; self monitoring and instrumental activities of daily living. Gerontologist. 1969; 9:179186. 11. Altkorn DL, Ramsdell JW, Jackson JE, Renvall M. Recommendations for a change in living situation resulting from an outpatient geriatric assessment: type, frequency and risk factors. J Am Geriatr Soc. 1991; 39:508-512. 12. Williams TF, Hill JG, Fairbank ME, Knox KG. Appropriate placement of the chronically ill and aged: a successful approach by evaluation. JAMA. 1973; 226:1332-1335. 13. Williams ME. Identifying the older person likely to require longterm care services. JAm GeriatrSoc. 1987; 35:761-766. 14. Lipschitz DA. An overview of anemia in older patients. Older Patient. 1988; 6:5-11 15. Foretta B, Tortrat D, Wolmark Y. Cholesterol as risk factor for mortality in elderly women. Lancet. 1989; 1:868-870.