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Nutritional Issues in Long-Term Care
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Nutritional Issues in Long-Term Care Philip D. Sloane, MD, MPH, Jena Ivey, PharmD, Margaret Helton, MD, Ann Louise Barrick, PhD, and Ana Cerna Because long-term care residents often have chronic illnesses and complex care regimens, nutritional issues are common in these populations. Furthermore, management is complicated because some residents are terminally ill and under palliative care treatment plans that allow for dehydration and low oral intake. As a result, the medical management of nutrition is complex and challenging for medical providers caring for residents of nursing homes, assisted living facilities, and other long-term care settings. Quality nutritional practice in long-term care involves careful assessment of barriers to adequate nutrition; reduction of risk factors; attention to spe-
cialized diets, food presentation, and supplements, when appropriate; awareness of the importance of psychosocial and environmental issues; and consideration of the role of medication both as a cause and a therapeutic adjunct. Optimal practice at a facility level would involve a systematic approach to applying the best evidence-based approaches, with a focus on individualizing each resident’s nutritional management. (J Am Med Dir Assoc 2008; 9: 476 – 485)
Maintaining good nutritional status of long-term care residents is an important challenge for clinicians working in these settings. Good practice and Centers for Medicare and Medicaid Services (CMS) standards dictate that every resident should be provided with sufficient food and fluids to maintain proper nutrition and hydration.1 However, because long-term care residents often have chronic illnesses and other factors that impair intake or require specialized regimens, nutrition and hydration problems are common in these populations. Furthermore, assessment and management of nutrition and hydration in these settings are complicated by the fact that some residents are terminally ill and under palliative care treatment plans that allow for dehydration and low oral intake. As a result, the medical management of nutrition is complex and challenging for medical providers caring for residents of nursing homes, assisted living facilities, and other long-term care settings.
In this article we review key issues in nutritional assessment and management in long-term care. These include risk factors for nutritional deficiency, assessment of nutrition and hydration status, the role of medications, psychosocial and environmental issues, and regulatory and ethical issues. The evidence addressing many of these issues is limited, although opinions and recommendations abound; when available, we have attempted to summarize and draw from the scientific literature. Our goal is to present a simple, practical, and as evidence-based as possible guide for health care practitioners on management of common nutritional problems that arise in long-term care.
Department of Family Medicine, School of Medicine, University of North Carolina at Chapel Hill (UNC-CH), Chapel Hill, NC (P.D.S., M.H.); Program on Aging, Disability, and Long-Term Care, Cecil G. Sheps Center for Health Services Research, UNC-CH (P.D.S., A.C.); School of Pharmacy, UNC-CH (J.I., A.C.); Department of Psychology, UNC-CH (A.L.B.); John Umstead Hospital, Butner, NC (A.L.B.). The authors have no conflicts of interest pertaining to this article. Address correspondence to Philip D. Sloane, MD, MPH, Cecil G. Sheps Center, 725 Martin Luther King Jr. Boulevard, University of North Carolina, Chapel Hill, NC 27599-7590. E-mail: [email protected]
Copyright ©2008 American Medical Directors Association DOI: 10.1016/j.jamda.2008.03.005 476 Sloane et al
Keywords: Nutrition; long-term care; nursing homes; assisted living
RISK FACTORS AND ASSESSMENT Poor nutrition and unintentional weight loss are common in institutionalized elderly, with prevalence estimates ranging from 2% to 41%.2 Medical conditions affecting weight loss can be classified into several categories: oral diseases, swallowing disorders, cognitive impairments and mental disorders, metabolic disorders, enteric problems, cerebrovascular accidents, cancer, chronic infections, and other chronic conditions such as chronic obstructive pulmonary disease (COPD), and diabetes.3 Dehydration is also a commonly unrecognized yet manageable condition in long-term care settings.4 Nursing home surveyors tend to screen for nutritional problems using CMS guidelines for “significant” weight loss, which instruct them to look for persons who have lost 5% or more of body weight in 30 days or 10% or more of body weight within 180 days. Significant weight loss is then categorized as expected or unintended. Weight loss is expected when a resiJAMDA – September 2008
Table 1. Common Causes of Dysphagia in Elderly Persons Swallowing Phase Affected
Typical Symptoms
Common Causes
Oropharyngeal phase
Difficulty initiating swallowing Coughing or choking with swallowing Food pocketing or sticking in back of mouth Drooling Changes in voice or speech Nasal regurgitation of food or liquids Sensation of food sticking in throat or chest Chest pain after swallowing Regurgitation after swallowing
Alzheimer’s disease and other dementias Stroke Parkinson’s disease Bulbar palsy Myasthenia gravis
Esophageal phase
dent is under end-of-life or palliative care, in which case the care plan should indicate that appropriate effort is being made to encourage and provide intake, and that the resident or a surrogate is aware of and in agreement with this plan. If unintended weight loss is present, the resident should be assessed for risk factors and nutritional intake, identified causes of weight loss addressed in the care plan, and interventions introduced to address the cause of the weight loss. If there is no improvement despite these efforts, then the weight loss is considered unavoidable. In addition to monitoring the resident’s weight, screening for nutritional deficiency in long-term care often includes measuring the serum hematocrit and the serum albumin. However, these tests are nonspecific, being affected by such problems as chronic renal disease, liver disease, and certain medications. A better method may be to use the Mini Nutritional Assessment (MNA)— 6 screening questions, which are followed up by 12 more in persons who screen positive— which can be completed in 15 minutes by a clinician such as a nurse practitioner.5 Since the MNA requires some resident responses, it is better suited for less impaired elderly, such as assisted living facility residents.6 The MNA can be downloaded at http://www.mna-elderly.com/clinical-practice.htm. A shorter assessment tool that measures appetite is the Simplified Nutritional Assessment Questionnaire, a 4-item screen that predicts weight loss in both community-dwelling adults and long-term care residents.7 Oral Health Oral health problems limit food choices and intake; therefore, they have a profound impact on nutritional status. Decayed or missing teeth, periodontal disease, missing and inadequate improper dentures, and decreased chewing capacity strongly correlate with reduced intake of calories, protein, fat, carbohydrates, fiber, calcium, and antioxidants, and with diminished enjoyment of eating.8 Oral health assessment tools include the Geriatric Oral Health Assessment Index, Subjective Oral Health Status Indicators, Oral Health Impact Profile-49, Dental Impact on Daily Living, Oral Health Impact Profile-14, and Oral Impact on Daily Performances.9 Potential courses of action include preventive dentistry, tooth replacement, use of REVIEWS
Esophageal neoplasm Esophageal infection (eg, candidiasis) Reflux disease with or without stricture Esophageal motility disturbances (eg, achalasia, scleroderma)
artificial saliva preparations, making sure dentures are fitting well, and inquiring about needed changes in food texture.8 Dysphagia Swallowing disorders affect between 40% and 60% of longterm care residents.10 In these settings, dysphagia is most commonly caused by dementia, but it can also be due to stroke, generalized weakness, decreased salivary flow, inflammatory diseases, infection, obstruction, and Parkinson’s disease (see Table 1). These causes of dysphagia can be divided into 2 subgroups, depending on the swallowing phase affected. ●
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Oropharyngeal dysphagia involves difficulty chewing, initiating swallowing, or achieving the neuromuscular coordination required for efficient food passage from the back of the mouth into the esophagus. Symptoms include coughing or choking, difficulty initiating swallowing, food sticking in the throat, drooling, recurrent pneumonia, change in voice or speech, and nasal regurgitation of food or liquids. Esophageal phase dysphagia refers to problems involving passage of food down the esophagus into the stomach. Symptoms suggesting esophageal dysphagia include a sensation of food sticking in the throat or chest, chest pain associated with swallowing, or regurgitation after initiation of swallowing.
Unexplained weight loss, change in dietary habits, or loss of desire to eat can be due to either phase of dysphagia or to problems in other areas.10,11 A whole health care industry has arisen around the evaluation of swallowing disorders. Key components of this industry include formal evaluation and testing by speech therapists, endoscopic evaluation by gastroenterologists, and radiographic diagnostic studies such as videofluoroscopy. Whether and when these specialized evaluations actually help resident management is controversial, and randomized trials are nonexistent. Practically speaking, most residents who have dysphagia can be evaluated by the primary care provider, working in concert with the facility nursing and nutrition staff. Evaluation should include a careful examination of the teeth, mouth, throat, and neck; observation of the context in which Sloane et al 477
the resident eats (positioning, alertness, food offered, assistance provided, and environment); and watching the patient eat foods of various consistencies (ie, thin liquids, thickened liquids, and various food types). The purposes of the evaluation are to (1) identify whether a problem is present and, if so, the extent to which it impairs intake; (2) identify treatable causes and risk factors; and (3) identify changes in food texture or presentation that may improve the situation. In patients with Parkinson’s disease and/or dementia, videofluorographic swallowing assessment was shown to help identify the best short-term intervention to prevent aspiration.12 Therefore, endoscopic or videofluorographic examinations may help identify the best intervention for a particular swallowing disorder. A knowledgeable, pragmatic speech pathologist can be a vital member of the health care team by providing evaluations and training as necessary. A particularly useful role for the speech pathologist is in the provision of individualized teaching to direct care staff about how to feed patients with swallowing disorders, which is something primary care providers are unlikely to provide. Furthermore, nurses can become distraught when they encounter patients that have difficulty opening their mouths, can’t swallow, have pocketed food, or choke frequently; in such situations, guidance from an experienced speech therapist can be helpful. Chronic Illness One or more chronic diseases are nearly always key factors underlying malnutrition and weight loss in long-term care residents. Dementia is most common; others include cancer, diabetes, osteoporosis with fracture, depression, malabsorption, infection, and COPD.13 In dementia the mechanism is usually inability to remember the voluntary steps required to eat and swallow; in COPD it is the increased work of breathing, combined with chronic fatigue; in chronic infection it is thought to be related to the release of cytokines.14 Depression is probably the most common reversible illness underlying undernutrition; in one study it was present in 36% of nursing home residents with unintentional weight loss.14 Depression has also been associated with anorexia, which can further increase the risk of nutritional problems.3 Malnutrition has been strongly associated with depression even after adjusting for other risk factors such as educational status, socioeconomic level, and smoking.15,16 For these reasons, a key to reducing malnutrition risk is to successfully treat chronic illnesses, particularly depression.3 ROLE OF MEDICATION Medication as a Cause of Weight Loss and Malnutrition Medications can induce weight loss in many different ways. Common mechanisms and typical causative agents include3,13: ●
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anorexia and/or nausea from digitalis, fluoxetine, sertraline, many other psychotropic agents, metronidazole, donepezil, or theophylline; gastrointestinal irritation from erythromycin or a nonsteroidal anti-inflammatory agent;
478 Sloane et al
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constipation from narcotics or a calcium channel antagonist; diarrhea from the sorbitol vehicle of certain suspensions (eg, theophylline); hypermetabolism due to excessive doses of levothyroxine or theophylline; and cognitive impairment and/or somnolence from a psychotropic medication, a narcotic, clonidine, or metoclopramide.
Table 2 provides additional detail regarding the drug classes and specific medications commonly associated with unintentional weight loss, and the mechanism by which they affect nutritional intake. Inadequate medication can also cause weight loss and malnutrition. For example, a reduction in psychotropic medication may cause weight loss by unmasking an underlying disorder such as anxiety or depression. Selection of Antidepressants in Older Residents with Anorexia and Weight Loss As noted earlier, depression is one of the major factors associated with malnutrition and weight loss in older persons. The mainstay of treatment should be antidepressant medication, supplemented with structured approaches to psychotherapy, if appropriate.17 However, clinicians must be cautious because many of the available antidepressants can themselves cause weight loss, either due to anorexia (selective serotonin uptake inhibitors [SSRIs]) or anticholinergic symptoms such as dry mouth and constipation (tricyclic antidepressants [TCAs]). Only a few short-term efficacy trials in older adults assess this issue; however, a general notion has developed that TCAs can enhance appetite and facilitate weight gain while SSRIs place depressed older persons at increased risk for significant weight loss.18 Evidence suggests that mirtazapine (Remeron) may be more effective than SSRIs in promoting weight gain, most likely because its mechanism of action is both seratonergic and noradrenergic.18 Transient somnolence, hyperphagia, and weight gain are the most commonly reported side effects, which may be attributed to the antihistaminic (H1) activity of mirtazapine at low doses; therefore, the desired side effect of weight gain may be less pronounced as the dose is increased.19 Other agents could be considered, depending on the clinical picture, since TCAs have been reported to be associated with weight gain,17,18 although their multitude of side effects limits their use, and the SSRIs may be weight neutral, depending on receptor affinity, dose, and duration of therapy.20 Appetite Stimulants In residents with weight loss who fail to respond to nonpharmacological measures, the question sometimes arises as to whether appetite stimulant (orexigenic) drugs would be helpful. Several drugs have been used to promote weight gain; however, none are approved by the US Food and Drug Administration (FDA) for the treatment of weight loss in older persons, and few have been studied in this population.14 JAMDA – September 2008
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Table 2. Common Drugs Causing Eating and Nutritional Problems Drug or Drug Class
Mechanism of Action in Contributing to Poor Eating and Weight Loss Confusion or Lethargy
Anticholinergics
X
Opioids
X
Decreased Appetite, Nausea/ Vomiting
Fluoxetine Benzodiazepenes
Alteration in Taste Receptors
Dry Mouth
Oropharyngeal Dysphagia
X
X
Esophageal Dysphagia
Abdominal Cramping, Bloating, or Diarrhea
Nutrient Malabsorption
Constipation
X
X
X
X X
Bisphosphonates
X
Psychotropics
X
X
X
Tricyclic antidepressants
X
X
X
ACEIs
X
Metformin
X
Bupropion
X
Chlorhexidine
X
Antineoplastics
X
Ipratropium Antiepileptics
X
Digoxin
X
Antibiotics
X
Alcohol
X
X
X X
X
X
X
X
X
X X
Antacids containing Al/Mg
X
Methotrexate
X
Sulfasalazine
X
Chronic laxative use
X
Sloane et al 479
Antihistamines
X
Corticosteroids Antispasmodics
X X
X
ACEIs, angiotensin converting enzyme inhibitors.
X
X
X
Dronabinol (Marinol) is a synthetic oral form of delta-9tetrahydrocannabinol (delta-9-THC), which is a naturally occurring component of Cannabis sativa. Dronabinol is approved by the FDA for the treatment of anorexia associated with weight loss in persons with AIDS, as well as to prevent vomiting in people receiving cancer chemotherapy. Based largely on efficacy and safety data derived from cohorts of subjects with AIDS-related cachexia, empirical use of dronabinol as an orexigenic agent is increasing in long-term care facilities.21 However, there is a striking paucity of data regarding the efficacy and safety of this agent in frail older adults. In a small clinical trial involving persons with Alzheimer’s disease, dronabinol-treated patients had higher increases in body weight versus placebo-treated patients over the 12-week treatment period, and none had adverse events requiring drug discontinuation.22 In a small observational study in a longterm care facility, 54% of residents treated with dronabinol gained weight and none had to discontinue therapy because of adverse effects.21 However, side effects of dizziness, confusion, and somnolence are commonly reported in patients with AIDS and cancer who are treated with dronabinol, and no studies in older persons to date have documented improvement in life expectancy or quality of life on the drug. Therefore, it is presently unclear if dronabinol should be used in frail long-term care residents, particularly those with cognitive decline. Megestrol (Megace), an oral derivative of progesterone, has been used for appetite stimulation in a variety of patient populations, and several clinical trials have studied its use in the long-term care setting. In one study, after 25 weeks the treatment group had gained an average of 3 kg, compared with an average weight loss of 0.5 kg in the control group.23 In another study of older nursing home residents who were losing weight and refused enteral feeding, megestrol acetate produced improvement in food take, body mass index, and serum albumin.24 In a noncontrolled trial of feeding assistance, 47% of long-term care subjects treated with megestrol acetate experienced weight gain (mean 5.9 lb); appetite was increased in 53%; and 41% reported an increase in energy.25 Improvements in appetite, well-being, and enjoyment of life have also been noted in nursing home patients treated with megestrol versus those receiving placebo, although no significant differences in weight gain were noted between the 2 groups after the 12-week treatment period.26 Common adverse effects include diarrhea, nausea, flatulence, rashes, and fatigue. The mechanism of action of megestrol appears to be increased body fat rather than lean body mass; however, any beneficial effects on survival and the most appropriate duration of therapy to achieve desired outcomes have not yet been demonstrated.24 Various other agents have been examined in persons with significant weight loss, with little proven efficacy. In randomized, placebo-controlled clinical trials, corticosteroids have improved appetite but have not demonstrated body-weight gain. Furthermore, corticosteroids produce significant adverse effects, such as gastritis, hyperglycemia, immune suppression, and muscle weakness.23 Cyproheptadine (Periactin) is an antihistamine and antiserotoninergic 480 Sloane et al
medication that causes a mild increase in appetite; in one study, persons (median age: 65 years) who received cyproheptadine had a decrease in their rate of weight loss but no weight gain.27 Drowsiness and dizziness are side effects that may make the use of this medication particularly problematic in older persons. Metoclopramide (Reglan), a prokinetic agent, may relieve nausea-induced anorexia but has been associated with a number of drug interactions, serious dystonia, and parkinsonian symptoms. Anabolic steroids and agents with anabolic properties (eg, oxandrolone and ornithine) have been used with some success to treat cachexia in patients with AIDS and cancer but have not been tested in older adults. Side effects include increased blood pressure and hematocrit, masculinizing effects in women, and prostatic changes in men. Recombinant human growth hormone (somatotropin) can increase lean body mass but is expensive and has adverse effects including carpal tunnel syndrome, headache, arthralgias, myalgias, worsened diabetic control, and gynecomastia. In conclusion, although some trials have demonstrated weight gain using some drugs in older persons, none have demonstrated improvement in long-term outcomes or quality of life. Therefore, if one of these agents is initiated, residents should be monitored closely for side effects. If residents using these medications have trouble chewing or swallowing, medications may need to be in liquid form, chewable, or crushed. Since side effects are common, any medication to promote weight gain should be withdrawn if meaningful weight gain is not achieved in an appropriate time frame. ROLE OF SPECIALIZED DIETS, FOOD PRESENTATION, AND SUPPLEMENTS Specialized Diets and Food Presentation In hospitals, specialized (“therapeutic”) diets are the norm, and are designed to address the nutritional needs of medical conditions such as hypertension, diabetes, and chronic renal disease. However, when prescribed in long-term care, they have been shown to be associated with unintended weight loss, because they restrict familiar foods and are often unpalatable. There is evidence that in long-term care settings, patients with diabetes can be successfully managed with a regular diet without a limit on concentrated sweets.28 As a result, the American Dietetic Association recommends that “quality of life and nutritional status of older residents in long-term care facilities may be enhanced by liberalization of the diet prescription.”29 Specific recommendations include: ●
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use medication adjustment instead of diet to control blood glucose, because having residents on regular diets will result in more consistent mealtimes, portion sizes, and carbohydrate intake, and because ‘no concentrated sweets’ diets have not been demonstrated to lower blood glucose30; liberalize sodium restriction to 4 to 6 g per day, although the DASH diet (2 to 3 g/d) is also recommended29,31; in persons with chronic renal disease, restrict protein intake to 0.6 to 0.8 g per day if not on dialysis (to delay the need for dialysis); if on dialysis, extra protein is needed and intake can be liberalized.29 JAMDA – September 2008
Focusing on pleasurable eating at mealtimes has potential to improve nutrition in nursing home residents because, although taste and smell decline with aging, older people are no different from younger people in desiring palatable food. Efforts to avoid repetitive, bland food by varying the diet in elderly nursing home residents have been associated with better nutritional status.32 Mechanically altering the texture of food is another common modification seen in long-term care settings, particularly in residents who have difficulty swallowing due to stroke, dementia, Parkinson’s disease, or Alzheimer’s disease. Information on the clinical efficacy of various dysphagia diets is limited. Ensuring adequate food intake among residents with dysphagia remains a challenge, and various attempts to address this have met with limited success. Providing smaller, more frequent meals did not improve food intake.32 Pureed or chopped foods that are prepared from the regular menu do not consistently provide sufficient protein levels for the residents consuming these diets.33 Dietary Supplements and Vitamin/Mineral Preparations A common approach to addressing the malnutrition and weight loss seen in nursing home residents is to augment caloric intake with oral supplements. European studies suggest that supplements are effective in preventing unintentional weight loss in the nursing home34 –36; but aside from these few studies there are limited data available regarding the appropriate timing, frequency, and amount of supplements to be provided and whether they are nutritionally beneficial. One study found that residents who were provided supplements were just as likely to lose as to gain weight, presumably because of the suppressive effect on appetite at regular meal times.37 Studies that counter this finding and suggest that supplements do not decrease the amount of food eaten at mealtime are limited by their retrospective nature and the absence of documentation of the quantity of the supplement that was actually consumed.38 A meta-analysis reported that oral nutritional supplements can improve nutritional status and reduce mortality for undernourished elderly patients in the hospital, but current evidence does not support routine supplementation for well-nourished older patients in any setting.39 In either case, supplements tend to be provided less frequently than intended, and staff spend minimal time assisting residents in taking them, with the consequence that caloric intake is minimally increased.40 Nursing home residents often also receive supplemental vitamins and minerals, despite the absence of data that this is beneficial. Because vitamins and minerals play an important role in immunity and because micronutrient deficiencies are common in nursing home residents,41 one might assume that vitamin and mineral supplementation would reduce infections. However despite this theoretical benefit and widely accepted clinical intuition, supplementation with multivitamins and minerals does not reduce the overall incidence of infections in frail older persons.42 The nutritional value of tube feeding for nursing home residents is highly controversial. Originally developed for use REVIEWS
in younger patients with isolated esophageal pathology, the contribution of feeding tubes to improved outcomes in older adults with chronic, progressive disease is largely unproven. Not surprisingly, advanced age and dementia are both negative risk factors for survival after percutaneous endoscopic gastrostomy (PEG) placement.43 According to a recent review, randomized trials have not been conducted; however, existing studies suggest that feeding tubes do not reduce the risk of death, aspiration pneumonia, infection, skin breakdown, or other adverse outcomes that they are often thought to prevent.44 Considering that hand feeding has been demonstrated to maintain weight and serum albumin levels in nursing home patients with feeding problems for as long as 6 years,45 but to require more staff time and increase care costs,46 the decision to insert a feeding tube appears to rest on factors other than nutrition.44,47 PSYCHOSOCIAL ISSUES Often, the most valuable approach to developing effective, individualized therapeutic interventions for persons with weight loss and poor food and/or fluid intake is to identify and address psychosocial issues. The process of identifying and optimally addressing these issues requires a careful, thorough assessment, development and implementation of an individualized treatment plan, and ongoing re-assessment and modification of the plan, using a quality improvement approach.48,49 In one published report of a quality improvement program focusing on feeding, for example, the following remediable factors were identified in over 50% of mealtime observations conducted as part of their assessment: lack of homelike dining room, too few dining chairs available, routine use of bibs without resident or family request, service of food before beverages, lack of alternatives being offered when food items were refused, food not removed from trays, staff not conversing with residents, and improper resident positioning.48 Psychosocial factors to be evaluated in developing treatment plans include personal factors such as pain, physical illness or limitations, cognitive impairment, or a need for control; relationship factors involving the interaction between care provider and resident; physical environmental factors such as dining room décor and noise; and organizational/policy factors such as the administrative attitude toward caregiver assistance time, flexibility, training, creativity, and work routines. Personal Issues Practically any chronic illness or physical disability can impair oral intake. Several of these (eg, dysphagia, oral health problems, and depression) have already been discussed. Particularly important are disorders that prevent self-feeding, such as hemiparesis, tremor, and fatigue. Sensory deficits such as hearing, taste, and visual loss likely affect intake as well; however, there is little research in this area. Assessment and adequate treatment for these conditions is essential. Occupational therapists can be especially helpful with adapting the environment and equipment to assist with impairment of both cognitive and physical functioning. Weighted silverware and plates with a colored rim have been helpful. Nursing can Sloane et al 481
Fig. 1. Tailoring the level of assistance: A principle of quality ADL care for persons with dementia. Optimal interactions around activities of daily living tend to occur when the resident’s level of cognitive impairment is matched by an appropriate level of assistance from staff. Thus, in working with persons who have feeding difficulty, staff should identify the level of assistance that best fits the persons capabilities and needs.
compensate for visual and hearing loss by modifying the meal set-up and by taking steps to reduce environmental noise. Dementia is probably the most prevalent personal issue affecting oral intake in the long-term care setting. With advancing dementia, self-feeding behavior is often lost as the person becomes unable to complete complex sequences involved in eating. Inability to recognize food or utensils, trouble getting the food to the mouth, distractibility, holding food or spitting it out, and turning the head away may also occur. Additionally, excessive walking or pacing related to cognitive impairment can interfere with a person’s ability to sit and eat as well as consume sufficient calories to avoid weight loss. The level of cognitive impairment influences the effectiveness of interventions. Persons with greater cognitive impairment drink more fluid when verbal prompts are increased. Persons who are cognitively intact increase their consumption only if given their preferred beverage. Those who can eat independently prefer to do so and respond to verbal cues but not physical guidance.50 Increased cognitive impairment, confusion, and behavioral difficulties have been associated with differences in diurnal eating patterns, in that persons with these characteristics tend to have their largest consumption of calories at breakfast and the least at dinner.51 A key principle of providing assistance with activities of daily living (ADLs) in persons with cognitive impairment is matching the level of assistance to the needs and capabilities of the individual. Figure 1 illustrates the application of this principle to feeding. Relationship Factors Several studies have examined the quality of the relationship between the caregiver and the person receiving assistance with eating. The importance of communication was demonstrated in a study of “family-style” meals, in which 482 Sloane et al
prompts and praise for appropriate behaviors during meals were associated with increases in both participation and communication.52 In another study, behaviors and interactive patterns of both those giving and receiving care were found to be poorly synchronized. For example, resident behaviors that indicated a desire to eat (eg, leaning forward, reaching for food, opening the mouth) were often ignored by caregivers, who tended to give random rather than resident-prompted cues (eg, reorienting the person to the meal, touching the person) to encourage acceptance of food. They concluded that mealtime function could be improved by permanently assigned staff who knew resident needs and provided consistent, systematic cues.53 Attending to the relationship through verbal prompting and positive reinforcement can improve the eating abilities of persons with dementia. However, mealtime staff activities are often rushed and task-focused, accompanied by little conversation or communication between staff and residents.54 This hurried approach to assistance is likely to engender anxiety among both residents and staff55; yet several persons who require total or near-total feeding assistance are often assigned to a single caregiver, resulting in an average of 6 to 9 minutes of feeding assistance per person per meal.56 In such a tense, hurried environment, staff understandingly become impatient with residents who eat slowly, issuing commands such as “open your mouth” or “eat, don’t talk.”57 In contrast, a relaxed, positive reciprocal interaction between the resident and the nursing assistant will increase food consumption.58 Physical Environment Noisy, institutional environments are associated with low food and fluid intake,59 and a noisy, chaotic dining room can agitate some residents and distract others from eating.53 Yet long-term care dining areas are often characterized by clattering plates and silverware, blaring televisions, and conversations (sometimes shouting) between caregivers.60 In spite of the distractions present in many dining areas, eating alone is associated with even lower intake.61 Typically, residents who eat in their rooms are served last; their food is often cold; they are not positioned properly; some food is hard for them to reach; and staff are rarely present to provide needed assistance. As a result, low food and fluid intake are common in persons who eat in their rooms.59 Therefore, if residents do not do well in the noisy, stimulusrich environment of a public eating area, a small group in a quiet corner or a different room will increase socialization and intake.62 If residents are reluctant to go to the dining room, an invitation and escort are often helpful.63 Organizational Issues Several organizational factors have been associated with poor intake. These include inadequate staffing, insufficient staff training, and inadequate supervision. Numerous studies have associated high resident:staff ratios with reduced resident intake.58,60 Training, especially regarding effective techniques for assisting cognitively impaired residents during mealtimes and snacks, is often inadequate.54,57,64,65 In one study, for examJAMDA – September 2008
ple, nursing assistants expressed a need for training regarding persons who won’t open their mouths or who don’t initiate swallowing. This lack of knowledge regarding feeding strategies can result in negative views of residents who are difficult to feed.66 Supervisory support is critical. In one study, nursing assistants had been trained in proper feeding techniques but did not consistently apply them. Residents were not correctly positioned; food was given too quickly; and staff seldom initiated conversations with residents they were feeding. When asked why they did not more consistently apply what they had learned, the participating nursing assistants said that organizational barriers kept them from doing so.54 Others have confirmed that nursing assistants often feel undervalued by supervising nurses and are reluctant to ask for help when they need it.67 A SYSTEMATIC APPROACH TO RESIDENTS WITH WEIGHT LOSS AND FEEDING PROBLEMS Much research remains to be done on methods of assisting persons with weight loss and feeding problems. At this point there is some evidence for the following: ●
●
●
●
Assess all residents for risk factors for nutrition and hydration problems. That assessment should include a focus on medications, pain, and depression; evaluate the level of assistance needed (see Figure 2); and identify the food and fluid preferences of the individual. In persons who can’t express their choices, consultation with family and observation of their behavior during meals may be necessary to determine likes and dislikes. Develop care plans based on these assessments, and implement the care plans using a quality improvement approach. Continuously reevaluate the processes used to ensure the most effective methods are used, as patient characteristics and needs will change over time. At the facility level, provide training in the principles of dementia care and in the specific interventions needed to assist persons with dementia with feeding. This training should include methods for prompting residents as well as preparing the person for the meal (eg, glasses, dentures, hearing aides), making casual conversation, and encouraging staff to ask for help when needed. Among the best references on approaching feeding problems are the free Web resources provided by UCLA’s Boren Center.68 To increase the number of persons available to offer assistance, use the “all hands on deck” approach. Teach other staff in the facility (eg, social workers, occupational therapists, business and office staff) to provide needed assistance at mealtimes. Alternatively, have non-nursing staff perform tasks such as transportation to the dining room, socialization, and meal tray delivery, so that nursing staff can provide feeding assistance. Others who could assist with feeding support and/or socialization at mealtimes, if appropriately trained, include volunteer meal companions and family members.
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Fig. 2. Psychological intervention decision tree for long-term care residents with impaired nutritional intake.
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Provide experienced, facilitative nurse supervision to nursing assistants during mealtimes. This supervision needs to clearly communicate specific needs and interventions for individual residents as well as demonstrate effective interventions. Corrective feedback needs to be respectful of the nursing assistant, support a team philosophy, and create a supportive learning environment. Document carefully the assessment and treatment approaches used by health care team members to address impaired intake and weight loss, and the discussions with and decisions made by patients and families around palliative approaches to nutrition. Hold regular meetings with nursing staff to discuss challenging cases and brainstorm methods for increasing food and fluid intake. For persons who do not respond to interventions such as prompting or snacks between meals, a more intensive assessment by a multidisciplinary team is recommended. Team members may include a nurse, physician, dietitian, activity staff, occupational therapist, and speech therapist. Involvement of the family and the individual are also important. This team approach addresses multiple areas that contribute to poor intake and can result in care plans that meet specific needs.
The implementation of many of these recommendations will likely require a shift in the culture of long-term care Sloane et al 483
facilities. More training and education of staff will likely be required, as well as collaboration with the resident and their families. Ongoing monitoring and reassessment of implementation strategies will be key to ensuring that they are effective. This shift is consistent with the current move to provide more person-directed, individualized care and thus to improve quality-of-life of long-term care facility residents. REFERENCES 1. Centers for Medicare and Medicaid Services, Department of Health and Human Services. Standards for long-term care facilities requirements for states and long term care facilities: quality of care. US Government Printing Office 2006; 42 CFR §483.25(i–j). 2. Pauly L, Stehle P, Volkert D. Nutritional situation of elderly nursing home residents. Z Gerontol Geriatr 2007;40:3–12. 3. Morley JE, Silver AJ. Nutritional issues in nursing home care. Ann Intern Med 1995;123:850 – 859. 4. Amella EJ. Feeding and hydration issues for older adults with dementia. Nurs Clin North Am 2004;39:607– 623. 5. Hudgens J, Langkamp-Henken B. The Mini Nutritional Assessment as an assessment tool in elders in long-term care. Nutr Clin Pract 2004;19: 463– 470. 6. Langkamp-Henken B. Usefulness of the MNA in the long-term and acute-care settings within the United States. J Nutr Health Aging 2006;10:502–506; discussion 506 –509. 7. Wilson MG, Thomas DR, Rubenstein LZ, et al. Appetite assessment: Simple appetite questionnaire predicts weight loss in community-dwelling adults and nursing home residents. Am J Clin Nutr 2005;82:1074 – 1081. 8. Sahyoun NR. Tooth and mouth problems and nutrition among older people. Generations 2004;28:18. 9. Hebling E, Pereira AC. Oral health-related quality of life: A critical appraisal of assessment tools used in elderly people. Gerodontology 2007;24:151–161. 10. Kayser-Jones J, Pengilly K. Dysphagia among nursing home residents. Geriatr Nurs 1999;20:77, 82, 84. 11. Palmer JB, Drennan JC, Baba M. Evaluation and treatment of swallowing impairments. Am Fam Physician 2000;61:2453–2462. 12. Logemann JA, Gensler G, Robbins J, et al. A randomized study of three interventions for aspiration of thin liquids in patients with dementia or Parkinson’s disease. J Speech Lang Hear Res 2008;51:173–183. 13. Huffman GB. Evaluating and treating unintentional weight loss in the elderly. Am Fam Physician 2002;65:640 – 650. 14. Bales CW, Fischer JG, Orenduff MC. Nutritional interventions for aged-related chronic disease. Generations 2004;28:54. 15. Morley JE, Kraenzle D. Causes of weight loss in a community nursing home. J Am Geriatr Soc 1994;42:583–585. 16. Cabrera MA, Mesas AE, Garcia AR, de Andrade SM. Malnutrition and depression among community-dwelling elderly people. J Am Med Dir Assoc 2007;8:582–584. 17. Robertson R, Montagnini M. Geriatric failure to thrive. Am Fam Physician 2004;70:343–350. 18. Rigler SK, Webb MJ, Redford L, et al. Weight outcomes among antidepressant users in nursing facilities. J Am Geriatr Soc 2001;49: 49 –55. 19. Fawcett J, Barkin RL. Review of the results from clinical studies on the efficacy, safety and tolerability of mirtazapine for the treatment of patients with major depression. J Affect Disord 1998;51:267–285. 20. Malone M. Medications associated with weight gain. Ann Pharmacother 2005;39:2046 –2055. 21. Wilson MG, Philpot C, Morley JE. Anorexia of aging in long-term care: Is dronabinol an effective appetite stimulant? A pilot study. J Nutr Health Aging 2007;11:195–198. 22. Volicer L, Stelly M, Morris J, et al. Effects of dronabinol on anorexia and disturbed behavior in patients with Alzheimer’s disease. Int J Geriatr Psychiatry 1997;12:913–919. 484 Sloane et al
23. Thomas D. Guidelines for the use of orexigenic drugs in long-term care. Nutr Clin Pract 2006;21:82– 87. 24. Karcic E, Philpot C, Morley JE. Treating malnutrition with megestrol acetate: Literature review and review of our experience. J Nutr Health Aging 2002;6:191–199. 25. Simmons S, Walker K, Osterweil D. The effect of megestrol acetate on oral food and fluid intake in nursing home residents: a pilot study. J Am Med Dir Assoc 2004;4:24 –30. 26. Yeh SS, Wu SY, Lee TP, et al. Improvement in quality-of-life measures and stimulation of weight gain after treatment with megestrol acetate oral suspension in geriatric cachexia: Results of a double-blind, placebocontrolled study. J Amer Geriatr Soc 2000;48:485– 492. 27. Kardinal CG, Loprinzi CL, Schaid DJ, et al. A controlled trial of cyproheptadine in cancer patients with anorexia and/or cachexia. Cancer 1990;65:2657–2662. 28. Tariq SH, Karcic E, Thomas DR, et al. The use of a no-concentratedsweets diet in the management of Type 2 diabetes in nursing homes. J Am Diet Assoc 2001;101:1463–1466. 29. American Dietetic Association. Liberalization of the diet prescription improves quality of life for older adults in long-term care. J Am Diet Assoc 2005;105:1955–1965. 30. National Heart, Lung, and Blood Institute. Your Guide to Lowering Your Blood Pressure With DASH. DASH Eating Plan. Available at: http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/new_dash. pdf. Accessed December 22, 2007. 31. Bernstein MA, Tucker KL, Ryan ND, et al. Higher dietary variety is associated with better nutritional status in frail elderly people. J Am Diet Assoc 2002;102:1096 –1104. 32. Taylor KA, Barr SI. Provision of small, frequent meals does not improve energy intake of elderly residents with dysphagia who live in an extendedcare facility. J Am Diet Assoc 2006;106:1115–1118. 33. Dahl WJ, Whiting SJ, Tyler RT. Protein content of pureed diets: Implications for planning. Can J Diet Pract Res 2007;68:99 –102. 34. Lauque S, Arnaud-Battandier F, Mansourian R, et al. Protein-energy oral supplementation in malnourished nursing-home residents: A controlled trial. Age Ageing 2000;29:51–56. 35. Wouters-Wesseling W, Wouters AE, Kleijer CN, et al. Study of the effect of a liquid nutrition supplement on the nutritional status of psycho-geriatric nursing home patients. Eur J Clin Nutr 2002;56:245– 251. 36. Faxen-Irving G, Andren-Olsson B, af Geijerstam A, et al. The effect of nutritional intervention in elderly subjects residing in group-living for the demented. Eur J Clin Nutr 2002;56:221–227. 37. Kayser-Jones J, Schell ES, Porter C, et al. A prospective study of the use of liquid oral dietary supplements in nursing homes. J Am Geriatr Soc 1998;46:1378 –1386. 38. Johnson LE, Dooley PA, Gleick JB. Oral nutritional supplement use in elderly nursing home patients. J Am Geriatr Soc 1993;41:947–952. 39. Milne AC, Avenell A, Potter J. Meta-analysis: Protein and energy supplementation in older people. Ann Intern Med 2006;144:37– 48. 40. Simmons SF, Patel AV. Home staff delivery of oral liquid nutritional supplements to residents at risk for unintentional weight loss. J Am Geriatr Soc 2006;54:919 –924. 41. Drinka PJ, Goodwin JS. Prevalence and consequences of vitamin deficiency in the nursing home: A critical review. J Am Geriatr Soc 1991; 39:1008 –1017. 42. Liu BA, McGeer A, McArthur MA, et al. Effect of multivitamin and mineral supplementation on episodes of infection in nursing home residents: A randomized, placebo-controlled study. J Am Geriatr Soc 2007; 55:35– 42. 43. Rimon E, Kagasky N, Levy S. Percutaneous endoscopic gastrostomy: Evidence of different prognosis in various patient subgroups. Age Aging 2005;34:353–357. 44. Finucane TE, Christmans C, Leff BA. Tube feeding in dementia: How incentives undermine health quality and patient safety. J Am Med Dir Assoc 2007;8:205–208. 45. Levinson Y, Dwolatzky T, Epstein A, et al. Is it possible to increase weight and maintain the protein status of debilitated elderly residents of nursing homes? J Gerontol A Biol Sci Med Sci 2005;60:878 – 881. JAMDA – September 2008
46. Mitchell SL, Buchanan JL, Littlehale S, Hamel MB. Tube-feeding versus hand-feeding nursing home residents with advanced dementia: A cost comparison. J Am Med Dir Assoc 2004;5:S22–29. 47. Mitchell SL, Teno JM, Roy J, et al. Clinical and organizational factors associated with feeding tube use among nursing home residents with advanced cognitive impairment. JAMA 2003;290:73– 80. 48. Schnelle JF, Ouslander JG, Osterweil D, Blumenthal S. Total quality management: Administrative and clinical applications in nursing homes. J Am Geriatr Soc 1993;41:1259 –1266. 49. Evans BC, Crogan NL. Quality improvement practices: Enhancing quality of life during mealtimes. J Nurses Staff Dev 2001;17:131–136. 50. Simmons S, Alessi C, Schnelle J. An intervention to increase fluid intake in nursing home residents: Prompting and preference compliance. J Am Geriatr Soc 2001;49:926 –933. 51. Young K, Greenwood C. Shift in diurnal feeding patterns in nursing home residents with Alzheimer’s disease. J Gerontol A Biol Sci Med Sci 2001;56:M700 –706. 52. Altus DE, Engelman KK, Mathews RM. Using family-style meals to increase participation and communication in persons with dementia. J Gerontol Nurs 2002;28:47–53. 53. Van Ort S, Phillips L. Feeding nursing home residents with Alzheimer’s disease. Geriatr Nurs 1992;13:249. 54. Pelletier C. What do certified nurse assistants actually know about dysphagia and feeding nursing home residents? Am J Speech Lang Pathol 2004;13:99 –113. 55. Sanders H. Nutrition management in long-term care. J Nutr Elder 1990;9:69 –74. 56. Simmons S, Osterweil D, Schnelle J. Improving food intake in nursing home residents with feeding assistance: A staffing analysis. J Gerontol A Biol Sci Med Sci 2001;56:M790 –94.
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57. Kayser-Jones J, Schell E. The mealtime experience of a cognitively impaired elder: Ineffective and effective strategies. J Gerontol Nurs 1997;23:33–39. 58. Amella EJ. Factors influencing the proportion of food consumed by nursing home residents with dementia. J Am Geriatr Soc 1999;47:879–885. 59. Reed P, Zimmerman S, Sloane P, et al. Characteristics associated with low food and fluid intake in long-term care residents with dementia. Gerontologist 2005;45:74 – 80. 60. Durnbaugh T, Haley B, Roberts S. Assessing problem feeding behaviors in mid-stage Alzheimer’s disease. Geriatr Nurs 1996;17:63– 67. 61. Simmons S, Levy-Storm L. The effect of dining location on nutritional care quality in nursing homes. J Nutr Health Aging 2005;9:434 – 439. 62. Littlewood S, Saedi S, Williams C. Mealtimes: A missed opportunity. J Dementia Care 1997;5:18 –19. 63. Simmons S, Levy-Storm L. The effect of staff practices on nursing home residents’ preferences: Implications for individualizing care. J Nutr Health Aging 2006;10:216 –221. 64. Coyne M, Hoskins L. Improving eating behaviors in dementia using behavioral strategies. Clin Nurs Res 1997;6:275–290. 65. Watson R, Deary I. Is there a relationship between feeding difficulty and nursing intervention in elderly people with dementia? NT Res 1996;1: 44 –54. 66. Astrom S, Nilsson M, Norberg A, Winblad B. Empathy, experience of burnout and attitudes towards demented patients among nursing staff in geriatric care. J Adv Nurs 1990;15:1236 –1244. 67. Crogan NL, Shultz JA. Nursing assistants’ perceptions of barriers to nutrition care for residents in long-term care facilities. J Nurses Staff Dev 2000;16:216 –221. 68. Borun Center. Weight Loss Prevention. Available at: http://borun.medsch. ucla.edu/modules/Weight_loss_prevention/default.htm. Accessed December 22, 2007.
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Nutritional Issues in Long-Term Care Philip D. Sloane, MD, MPH, Jena Ivey, PharmD, Margaret Helton, MD, Ann Louise Barrick, PhD, and Ana Cerna Because long-term care residents often have chronic illnesses and complex care regimens, nutritional issues are common in these populations. Furthermore, management is complicated because some residents are terminally ill and under palliative care treatment plans that allow for dehydration and low oral intake. As a result, the medical management of nutrition is complex and challenging for medical providers caring for residents of nursing homes, assisted living facilities, and other long-term care settings. Quality nutritional practice in long-term care involves careful assessment of barriers to adequate nutrition; reduction of risk factors; attention to spe-
cialized diets, food presentation, and supplements, when appropriate; awareness of the importance of psychosocial and environmental issues; and consideration of the role of medication both as a cause and a therapeutic adjunct. Optimal practice at a facility level would involve a systematic approach to applying the best evidence-based approaches, with a focus on individualizing each resident’s nutritional management. (J Am Med Dir Assoc 2008; 9: 476 – 485)
Maintaining good nutritional status of long-term care residents is an important challenge for clinicians working in these settings. Good practice and Centers for Medicare and Medicaid Services (CMS) standards dictate that every resident should be provided with sufficient food and fluids to maintain proper nutrition and hydration.1 However, because long-term care residents often have chronic illnesses and other factors that impair intake or require specialized regimens, nutrition and hydration problems are common in these populations. Furthermore, assessment and management of nutrition and hydration in these settings are complicated by the fact that some residents are terminally ill and under palliative care treatment plans that allow for dehydration and low oral intake. As a result, the medical management of nutrition is complex and challenging for medical providers caring for residents of nursing homes, assisted living facilities, and other long-term care settings.
In this article we review key issues in nutritional assessment and management in long-term care. These include risk factors for nutritional deficiency, assessment of nutrition and hydration status, the role of medications, psychosocial and environmental issues, and regulatory and ethical issues. The evidence addressing many of these issues is limited, although opinions and recommendations abound; when available, we have attempted to summarize and draw from the scientific literature. Our goal is to present a simple, practical, and as evidence-based as possible guide for health care practitioners on management of common nutritional problems that arise in long-term care.
Department of Family Medicine, School of Medicine, University of North Carolina at Chapel Hill (UNC-CH), Chapel Hill, NC (P.D.S., M.H.); Program on Aging, Disability, and Long-Term Care, Cecil G. Sheps Center for Health Services Research, UNC-CH (P.D.S., A.C.); School of Pharmacy, UNC-CH (J.I., A.C.); Department of Psychology, UNC-CH (A.L.B.); John Umstead Hospital, Butner, NC (A.L.B.). The authors have no conflicts of interest pertaining to this article. Address correspondence to Philip D. Sloane, MD, MPH, Cecil G. Sheps Center, 725 Martin Luther King Jr. Boulevard, University of North Carolina, Chapel Hill, NC 27599-7590. E-mail: [email protected]
Copyright ©2008 American Medical Directors Association DOI: 10.1016/j.jamda.2008.03.005 476 Sloane et al
Keywords: Nutrition; long-term care; nursing homes; assisted living
RISK FACTORS AND ASSESSMENT Poor nutrition and unintentional weight loss are common in institutionalized elderly, with prevalence estimates ranging from 2% to 41%.2 Medical conditions affecting weight loss can be classified into several categories: oral diseases, swallowing disorders, cognitive impairments and mental disorders, metabolic disorders, enteric problems, cerebrovascular accidents, cancer, chronic infections, and other chronic conditions such as chronic obstructive pulmonary disease (COPD), and diabetes.3 Dehydration is also a commonly unrecognized yet manageable condition in long-term care settings.4 Nursing home surveyors tend to screen for nutritional problems using CMS guidelines for “significant” weight loss, which instruct them to look for persons who have lost 5% or more of body weight in 30 days or 10% or more of body weight within 180 days. Significant weight loss is then categorized as expected or unintended. Weight loss is expected when a resiJAMDA – September 2008
Table 1. Common Causes of Dysphagia in Elderly Persons Swallowing Phase Affected
Typical Symptoms
Common Causes
Oropharyngeal phase
Difficulty initiating swallowing Coughing or choking with swallowing Food pocketing or sticking in back of mouth Drooling Changes in voice or speech Nasal regurgitation of food or liquids Sensation of food sticking in throat or chest Chest pain after swallowing Regurgitation after swallowing
Alzheimer’s disease and other dementias Stroke Parkinson’s disease Bulbar palsy Myasthenia gravis
Esophageal phase
dent is under end-of-life or palliative care, in which case the care plan should indicate that appropriate effort is being made to encourage and provide intake, and that the resident or a surrogate is aware of and in agreement with this plan. If unintended weight loss is present, the resident should be assessed for risk factors and nutritional intake, identified causes of weight loss addressed in the care plan, and interventions introduced to address the cause of the weight loss. If there is no improvement despite these efforts, then the weight loss is considered unavoidable. In addition to monitoring the resident’s weight, screening for nutritional deficiency in long-term care often includes measuring the serum hematocrit and the serum albumin. However, these tests are nonspecific, being affected by such problems as chronic renal disease, liver disease, and certain medications. A better method may be to use the Mini Nutritional Assessment (MNA)— 6 screening questions, which are followed up by 12 more in persons who screen positive— which can be completed in 15 minutes by a clinician such as a nurse practitioner.5 Since the MNA requires some resident responses, it is better suited for less impaired elderly, such as assisted living facility residents.6 The MNA can be downloaded at http://www.mna-elderly.com/clinical-practice.htm. A shorter assessment tool that measures appetite is the Simplified Nutritional Assessment Questionnaire, a 4-item screen that predicts weight loss in both community-dwelling adults and long-term care residents.7 Oral Health Oral health problems limit food choices and intake; therefore, they have a profound impact on nutritional status. Decayed or missing teeth, periodontal disease, missing and inadequate improper dentures, and decreased chewing capacity strongly correlate with reduced intake of calories, protein, fat, carbohydrates, fiber, calcium, and antioxidants, and with diminished enjoyment of eating.8 Oral health assessment tools include the Geriatric Oral Health Assessment Index, Subjective Oral Health Status Indicators, Oral Health Impact Profile-49, Dental Impact on Daily Living, Oral Health Impact Profile-14, and Oral Impact on Daily Performances.9 Potential courses of action include preventive dentistry, tooth replacement, use of REVIEWS
Esophageal neoplasm Esophageal infection (eg, candidiasis) Reflux disease with or without stricture Esophageal motility disturbances (eg, achalasia, scleroderma)
artificial saliva preparations, making sure dentures are fitting well, and inquiring about needed changes in food texture.8 Dysphagia Swallowing disorders affect between 40% and 60% of longterm care residents.10 In these settings, dysphagia is most commonly caused by dementia, but it can also be due to stroke, generalized weakness, decreased salivary flow, inflammatory diseases, infection, obstruction, and Parkinson’s disease (see Table 1). These causes of dysphagia can be divided into 2 subgroups, depending on the swallowing phase affected. ●
●
Oropharyngeal dysphagia involves difficulty chewing, initiating swallowing, or achieving the neuromuscular coordination required for efficient food passage from the back of the mouth into the esophagus. Symptoms include coughing or choking, difficulty initiating swallowing, food sticking in the throat, drooling, recurrent pneumonia, change in voice or speech, and nasal regurgitation of food or liquids. Esophageal phase dysphagia refers to problems involving passage of food down the esophagus into the stomach. Symptoms suggesting esophageal dysphagia include a sensation of food sticking in the throat or chest, chest pain associated with swallowing, or regurgitation after initiation of swallowing.
Unexplained weight loss, change in dietary habits, or loss of desire to eat can be due to either phase of dysphagia or to problems in other areas.10,11 A whole health care industry has arisen around the evaluation of swallowing disorders. Key components of this industry include formal evaluation and testing by speech therapists, endoscopic evaluation by gastroenterologists, and radiographic diagnostic studies such as videofluoroscopy. Whether and when these specialized evaluations actually help resident management is controversial, and randomized trials are nonexistent. Practically speaking, most residents who have dysphagia can be evaluated by the primary care provider, working in concert with the facility nursing and nutrition staff. Evaluation should include a careful examination of the teeth, mouth, throat, and neck; observation of the context in which Sloane et al 477
the resident eats (positioning, alertness, food offered, assistance provided, and environment); and watching the patient eat foods of various consistencies (ie, thin liquids, thickened liquids, and various food types). The purposes of the evaluation are to (1) identify whether a problem is present and, if so, the extent to which it impairs intake; (2) identify treatable causes and risk factors; and (3) identify changes in food texture or presentation that may improve the situation. In patients with Parkinson’s disease and/or dementia, videofluorographic swallowing assessment was shown to help identify the best short-term intervention to prevent aspiration.12 Therefore, endoscopic or videofluorographic examinations may help identify the best intervention for a particular swallowing disorder. A knowledgeable, pragmatic speech pathologist can be a vital member of the health care team by providing evaluations and training as necessary. A particularly useful role for the speech pathologist is in the provision of individualized teaching to direct care staff about how to feed patients with swallowing disorders, which is something primary care providers are unlikely to provide. Furthermore, nurses can become distraught when they encounter patients that have difficulty opening their mouths, can’t swallow, have pocketed food, or choke frequently; in such situations, guidance from an experienced speech therapist can be helpful. Chronic Illness One or more chronic diseases are nearly always key factors underlying malnutrition and weight loss in long-term care residents. Dementia is most common; others include cancer, diabetes, osteoporosis with fracture, depression, malabsorption, infection, and COPD.13 In dementia the mechanism is usually inability to remember the voluntary steps required to eat and swallow; in COPD it is the increased work of breathing, combined with chronic fatigue; in chronic infection it is thought to be related to the release of cytokines.14 Depression is probably the most common reversible illness underlying undernutrition; in one study it was present in 36% of nursing home residents with unintentional weight loss.14 Depression has also been associated with anorexia, which can further increase the risk of nutritional problems.3 Malnutrition has been strongly associated with depression even after adjusting for other risk factors such as educational status, socioeconomic level, and smoking.15,16 For these reasons, a key to reducing malnutrition risk is to successfully treat chronic illnesses, particularly depression.3 ROLE OF MEDICATION Medication as a Cause of Weight Loss and Malnutrition Medications can induce weight loss in many different ways. Common mechanisms and typical causative agents include3,13: ●
●
anorexia and/or nausea from digitalis, fluoxetine, sertraline, many other psychotropic agents, metronidazole, donepezil, or theophylline; gastrointestinal irritation from erythromycin or a nonsteroidal anti-inflammatory agent;
478 Sloane et al
● ● ● ●
constipation from narcotics or a calcium channel antagonist; diarrhea from the sorbitol vehicle of certain suspensions (eg, theophylline); hypermetabolism due to excessive doses of levothyroxine or theophylline; and cognitive impairment and/or somnolence from a psychotropic medication, a narcotic, clonidine, or metoclopramide.
Table 2 provides additional detail regarding the drug classes and specific medications commonly associated with unintentional weight loss, and the mechanism by which they affect nutritional intake. Inadequate medication can also cause weight loss and malnutrition. For example, a reduction in psychotropic medication may cause weight loss by unmasking an underlying disorder such as anxiety or depression. Selection of Antidepressants in Older Residents with Anorexia and Weight Loss As noted earlier, depression is one of the major factors associated with malnutrition and weight loss in older persons. The mainstay of treatment should be antidepressant medication, supplemented with structured approaches to psychotherapy, if appropriate.17 However, clinicians must be cautious because many of the available antidepressants can themselves cause weight loss, either due to anorexia (selective serotonin uptake inhibitors [SSRIs]) or anticholinergic symptoms such as dry mouth and constipation (tricyclic antidepressants [TCAs]). Only a few short-term efficacy trials in older adults assess this issue; however, a general notion has developed that TCAs can enhance appetite and facilitate weight gain while SSRIs place depressed older persons at increased risk for significant weight loss.18 Evidence suggests that mirtazapine (Remeron) may be more effective than SSRIs in promoting weight gain, most likely because its mechanism of action is both seratonergic and noradrenergic.18 Transient somnolence, hyperphagia, and weight gain are the most commonly reported side effects, which may be attributed to the antihistaminic (H1) activity of mirtazapine at low doses; therefore, the desired side effect of weight gain may be less pronounced as the dose is increased.19 Other agents could be considered, depending on the clinical picture, since TCAs have been reported to be associated with weight gain,17,18 although their multitude of side effects limits their use, and the SSRIs may be weight neutral, depending on receptor affinity, dose, and duration of therapy.20 Appetite Stimulants In residents with weight loss who fail to respond to nonpharmacological measures, the question sometimes arises as to whether appetite stimulant (orexigenic) drugs would be helpful. Several drugs have been used to promote weight gain; however, none are approved by the US Food and Drug Administration (FDA) for the treatment of weight loss in older persons, and few have been studied in this population.14 JAMDA – September 2008
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Table 2. Common Drugs Causing Eating and Nutritional Problems Drug or Drug Class
Mechanism of Action in Contributing to Poor Eating and Weight Loss Confusion or Lethargy
Anticholinergics
X
Opioids
X
Decreased Appetite, Nausea/ Vomiting
Fluoxetine Benzodiazepenes
Alteration in Taste Receptors
Dry Mouth
Oropharyngeal Dysphagia
X
X
Esophageal Dysphagia
Abdominal Cramping, Bloating, or Diarrhea
Nutrient Malabsorption
Constipation
X
X
X
X X
Bisphosphonates
X
Psychotropics
X
X
X
Tricyclic antidepressants
X
X
X
ACEIs
X
Metformin
X
Bupropion
X
Chlorhexidine
X
Antineoplastics
X
Ipratropium Antiepileptics
X
Digoxin
X
Antibiotics
X
Alcohol
X
X
X X
X
X
X
X
X
X X
Antacids containing Al/Mg
X
Methotrexate
X
Sulfasalazine
X
Chronic laxative use
X
Sloane et al 479
Antihistamines
X
Corticosteroids Antispasmodics
X X
X
ACEIs, angiotensin converting enzyme inhibitors.
X
X
X
Dronabinol (Marinol) is a synthetic oral form of delta-9tetrahydrocannabinol (delta-9-THC), which is a naturally occurring component of Cannabis sativa. Dronabinol is approved by the FDA for the treatment of anorexia associated with weight loss in persons with AIDS, as well as to prevent vomiting in people receiving cancer chemotherapy. Based largely on efficacy and safety data derived from cohorts of subjects with AIDS-related cachexia, empirical use of dronabinol as an orexigenic agent is increasing in long-term care facilities.21 However, there is a striking paucity of data regarding the efficacy and safety of this agent in frail older adults. In a small clinical trial involving persons with Alzheimer’s disease, dronabinol-treated patients had higher increases in body weight versus placebo-treated patients over the 12-week treatment period, and none had adverse events requiring drug discontinuation.22 In a small observational study in a longterm care facility, 54% of residents treated with dronabinol gained weight and none had to discontinue therapy because of adverse effects.21 However, side effects of dizziness, confusion, and somnolence are commonly reported in patients with AIDS and cancer who are treated with dronabinol, and no studies in older persons to date have documented improvement in life expectancy or quality of life on the drug. Therefore, it is presently unclear if dronabinol should be used in frail long-term care residents, particularly those with cognitive decline. Megestrol (Megace), an oral derivative of progesterone, has been used for appetite stimulation in a variety of patient populations, and several clinical trials have studied its use in the long-term care setting. In one study, after 25 weeks the treatment group had gained an average of 3 kg, compared with an average weight loss of 0.5 kg in the control group.23 In another study of older nursing home residents who were losing weight and refused enteral feeding, megestrol acetate produced improvement in food take, body mass index, and serum albumin.24 In a noncontrolled trial of feeding assistance, 47% of long-term care subjects treated with megestrol acetate experienced weight gain (mean 5.9 lb); appetite was increased in 53%; and 41% reported an increase in energy.25 Improvements in appetite, well-being, and enjoyment of life have also been noted in nursing home patients treated with megestrol versus those receiving placebo, although no significant differences in weight gain were noted between the 2 groups after the 12-week treatment period.26 Common adverse effects include diarrhea, nausea, flatulence, rashes, and fatigue. The mechanism of action of megestrol appears to be increased body fat rather than lean body mass; however, any beneficial effects on survival and the most appropriate duration of therapy to achieve desired outcomes have not yet been demonstrated.24 Various other agents have been examined in persons with significant weight loss, with little proven efficacy. In randomized, placebo-controlled clinical trials, corticosteroids have improved appetite but have not demonstrated body-weight gain. Furthermore, corticosteroids produce significant adverse effects, such as gastritis, hyperglycemia, immune suppression, and muscle weakness.23 Cyproheptadine (Periactin) is an antihistamine and antiserotoninergic 480 Sloane et al
medication that causes a mild increase in appetite; in one study, persons (median age: 65 years) who received cyproheptadine had a decrease in their rate of weight loss but no weight gain.27 Drowsiness and dizziness are side effects that may make the use of this medication particularly problematic in older persons. Metoclopramide (Reglan), a prokinetic agent, may relieve nausea-induced anorexia but has been associated with a number of drug interactions, serious dystonia, and parkinsonian symptoms. Anabolic steroids and agents with anabolic properties (eg, oxandrolone and ornithine) have been used with some success to treat cachexia in patients with AIDS and cancer but have not been tested in older adults. Side effects include increased blood pressure and hematocrit, masculinizing effects in women, and prostatic changes in men. Recombinant human growth hormone (somatotropin) can increase lean body mass but is expensive and has adverse effects including carpal tunnel syndrome, headache, arthralgias, myalgias, worsened diabetic control, and gynecomastia. In conclusion, although some trials have demonstrated weight gain using some drugs in older persons, none have demonstrated improvement in long-term outcomes or quality of life. Therefore, if one of these agents is initiated, residents should be monitored closely for side effects. If residents using these medications have trouble chewing or swallowing, medications may need to be in liquid form, chewable, or crushed. Since side effects are common, any medication to promote weight gain should be withdrawn if meaningful weight gain is not achieved in an appropriate time frame. ROLE OF SPECIALIZED DIETS, FOOD PRESENTATION, AND SUPPLEMENTS Specialized Diets and Food Presentation In hospitals, specialized (“therapeutic”) diets are the norm, and are designed to address the nutritional needs of medical conditions such as hypertension, diabetes, and chronic renal disease. However, when prescribed in long-term care, they have been shown to be associated with unintended weight loss, because they restrict familiar foods and are often unpalatable. There is evidence that in long-term care settings, patients with diabetes can be successfully managed with a regular diet without a limit on concentrated sweets.28 As a result, the American Dietetic Association recommends that “quality of life and nutritional status of older residents in long-term care facilities may be enhanced by liberalization of the diet prescription.”29 Specific recommendations include: ●
● ●
use medication adjustment instead of diet to control blood glucose, because having residents on regular diets will result in more consistent mealtimes, portion sizes, and carbohydrate intake, and because ‘no concentrated sweets’ diets have not been demonstrated to lower blood glucose30; liberalize sodium restriction to 4 to 6 g per day, although the DASH diet (2 to 3 g/d) is also recommended29,31; in persons with chronic renal disease, restrict protein intake to 0.6 to 0.8 g per day if not on dialysis (to delay the need for dialysis); if on dialysis, extra protein is needed and intake can be liberalized.29 JAMDA – September 2008
Focusing on pleasurable eating at mealtimes has potential to improve nutrition in nursing home residents because, although taste and smell decline with aging, older people are no different from younger people in desiring palatable food. Efforts to avoid repetitive, bland food by varying the diet in elderly nursing home residents have been associated with better nutritional status.32 Mechanically altering the texture of food is another common modification seen in long-term care settings, particularly in residents who have difficulty swallowing due to stroke, dementia, Parkinson’s disease, or Alzheimer’s disease. Information on the clinical efficacy of various dysphagia diets is limited. Ensuring adequate food intake among residents with dysphagia remains a challenge, and various attempts to address this have met with limited success. Providing smaller, more frequent meals did not improve food intake.32 Pureed or chopped foods that are prepared from the regular menu do not consistently provide sufficient protein levels for the residents consuming these diets.33 Dietary Supplements and Vitamin/Mineral Preparations A common approach to addressing the malnutrition and weight loss seen in nursing home residents is to augment caloric intake with oral supplements. European studies suggest that supplements are effective in preventing unintentional weight loss in the nursing home34 –36; but aside from these few studies there are limited data available regarding the appropriate timing, frequency, and amount of supplements to be provided and whether they are nutritionally beneficial. One study found that residents who were provided supplements were just as likely to lose as to gain weight, presumably because of the suppressive effect on appetite at regular meal times.37 Studies that counter this finding and suggest that supplements do not decrease the amount of food eaten at mealtime are limited by their retrospective nature and the absence of documentation of the quantity of the supplement that was actually consumed.38 A meta-analysis reported that oral nutritional supplements can improve nutritional status and reduce mortality for undernourished elderly patients in the hospital, but current evidence does not support routine supplementation for well-nourished older patients in any setting.39 In either case, supplements tend to be provided less frequently than intended, and staff spend minimal time assisting residents in taking them, with the consequence that caloric intake is minimally increased.40 Nursing home residents often also receive supplemental vitamins and minerals, despite the absence of data that this is beneficial. Because vitamins and minerals play an important role in immunity and because micronutrient deficiencies are common in nursing home residents,41 one might assume that vitamin and mineral supplementation would reduce infections. However despite this theoretical benefit and widely accepted clinical intuition, supplementation with multivitamins and minerals does not reduce the overall incidence of infections in frail older persons.42 The nutritional value of tube feeding for nursing home residents is highly controversial. Originally developed for use REVIEWS
in younger patients with isolated esophageal pathology, the contribution of feeding tubes to improved outcomes in older adults with chronic, progressive disease is largely unproven. Not surprisingly, advanced age and dementia are both negative risk factors for survival after percutaneous endoscopic gastrostomy (PEG) placement.43 According to a recent review, randomized trials have not been conducted; however, existing studies suggest that feeding tubes do not reduce the risk of death, aspiration pneumonia, infection, skin breakdown, or other adverse outcomes that they are often thought to prevent.44 Considering that hand feeding has been demonstrated to maintain weight and serum albumin levels in nursing home patients with feeding problems for as long as 6 years,45 but to require more staff time and increase care costs,46 the decision to insert a feeding tube appears to rest on factors other than nutrition.44,47 PSYCHOSOCIAL ISSUES Often, the most valuable approach to developing effective, individualized therapeutic interventions for persons with weight loss and poor food and/or fluid intake is to identify and address psychosocial issues. The process of identifying and optimally addressing these issues requires a careful, thorough assessment, development and implementation of an individualized treatment plan, and ongoing re-assessment and modification of the plan, using a quality improvement approach.48,49 In one published report of a quality improvement program focusing on feeding, for example, the following remediable factors were identified in over 50% of mealtime observations conducted as part of their assessment: lack of homelike dining room, too few dining chairs available, routine use of bibs without resident or family request, service of food before beverages, lack of alternatives being offered when food items were refused, food not removed from trays, staff not conversing with residents, and improper resident positioning.48 Psychosocial factors to be evaluated in developing treatment plans include personal factors such as pain, physical illness or limitations, cognitive impairment, or a need for control; relationship factors involving the interaction between care provider and resident; physical environmental factors such as dining room décor and noise; and organizational/policy factors such as the administrative attitude toward caregiver assistance time, flexibility, training, creativity, and work routines. Personal Issues Practically any chronic illness or physical disability can impair oral intake. Several of these (eg, dysphagia, oral health problems, and depression) have already been discussed. Particularly important are disorders that prevent self-feeding, such as hemiparesis, tremor, and fatigue. Sensory deficits such as hearing, taste, and visual loss likely affect intake as well; however, there is little research in this area. Assessment and adequate treatment for these conditions is essential. Occupational therapists can be especially helpful with adapting the environment and equipment to assist with impairment of both cognitive and physical functioning. Weighted silverware and plates with a colored rim have been helpful. Nursing can Sloane et al 481
Fig. 1. Tailoring the level of assistance: A principle of quality ADL care for persons with dementia. Optimal interactions around activities of daily living tend to occur when the resident’s level of cognitive impairment is matched by an appropriate level of assistance from staff. Thus, in working with persons who have feeding difficulty, staff should identify the level of assistance that best fits the persons capabilities and needs.
compensate for visual and hearing loss by modifying the meal set-up and by taking steps to reduce environmental noise. Dementia is probably the most prevalent personal issue affecting oral intake in the long-term care setting. With advancing dementia, self-feeding behavior is often lost as the person becomes unable to complete complex sequences involved in eating. Inability to recognize food or utensils, trouble getting the food to the mouth, distractibility, holding food or spitting it out, and turning the head away may also occur. Additionally, excessive walking or pacing related to cognitive impairment can interfere with a person’s ability to sit and eat as well as consume sufficient calories to avoid weight loss. The level of cognitive impairment influences the effectiveness of interventions. Persons with greater cognitive impairment drink more fluid when verbal prompts are increased. Persons who are cognitively intact increase their consumption only if given their preferred beverage. Those who can eat independently prefer to do so and respond to verbal cues but not physical guidance.50 Increased cognitive impairment, confusion, and behavioral difficulties have been associated with differences in diurnal eating patterns, in that persons with these characteristics tend to have their largest consumption of calories at breakfast and the least at dinner.51 A key principle of providing assistance with activities of daily living (ADLs) in persons with cognitive impairment is matching the level of assistance to the needs and capabilities of the individual. Figure 1 illustrates the application of this principle to feeding. Relationship Factors Several studies have examined the quality of the relationship between the caregiver and the person receiving assistance with eating. The importance of communication was demonstrated in a study of “family-style” meals, in which 482 Sloane et al
prompts and praise for appropriate behaviors during meals were associated with increases in both participation and communication.52 In another study, behaviors and interactive patterns of both those giving and receiving care were found to be poorly synchronized. For example, resident behaviors that indicated a desire to eat (eg, leaning forward, reaching for food, opening the mouth) were often ignored by caregivers, who tended to give random rather than resident-prompted cues (eg, reorienting the person to the meal, touching the person) to encourage acceptance of food. They concluded that mealtime function could be improved by permanently assigned staff who knew resident needs and provided consistent, systematic cues.53 Attending to the relationship through verbal prompting and positive reinforcement can improve the eating abilities of persons with dementia. However, mealtime staff activities are often rushed and task-focused, accompanied by little conversation or communication between staff and residents.54 This hurried approach to assistance is likely to engender anxiety among both residents and staff55; yet several persons who require total or near-total feeding assistance are often assigned to a single caregiver, resulting in an average of 6 to 9 minutes of feeding assistance per person per meal.56 In such a tense, hurried environment, staff understandingly become impatient with residents who eat slowly, issuing commands such as “open your mouth” or “eat, don’t talk.”57 In contrast, a relaxed, positive reciprocal interaction between the resident and the nursing assistant will increase food consumption.58 Physical Environment Noisy, institutional environments are associated with low food and fluid intake,59 and a noisy, chaotic dining room can agitate some residents and distract others from eating.53 Yet long-term care dining areas are often characterized by clattering plates and silverware, blaring televisions, and conversations (sometimes shouting) between caregivers.60 In spite of the distractions present in many dining areas, eating alone is associated with even lower intake.61 Typically, residents who eat in their rooms are served last; their food is often cold; they are not positioned properly; some food is hard for them to reach; and staff are rarely present to provide needed assistance. As a result, low food and fluid intake are common in persons who eat in their rooms.59 Therefore, if residents do not do well in the noisy, stimulusrich environment of a public eating area, a small group in a quiet corner or a different room will increase socialization and intake.62 If residents are reluctant to go to the dining room, an invitation and escort are often helpful.63 Organizational Issues Several organizational factors have been associated with poor intake. These include inadequate staffing, insufficient staff training, and inadequate supervision. Numerous studies have associated high resident:staff ratios with reduced resident intake.58,60 Training, especially regarding effective techniques for assisting cognitively impaired residents during mealtimes and snacks, is often inadequate.54,57,64,65 In one study, for examJAMDA – September 2008
ple, nursing assistants expressed a need for training regarding persons who won’t open their mouths or who don’t initiate swallowing. This lack of knowledge regarding feeding strategies can result in negative views of residents who are difficult to feed.66 Supervisory support is critical. In one study, nursing assistants had been trained in proper feeding techniques but did not consistently apply them. Residents were not correctly positioned; food was given too quickly; and staff seldom initiated conversations with residents they were feeding. When asked why they did not more consistently apply what they had learned, the participating nursing assistants said that organizational barriers kept them from doing so.54 Others have confirmed that nursing assistants often feel undervalued by supervising nurses and are reluctant to ask for help when they need it.67 A SYSTEMATIC APPROACH TO RESIDENTS WITH WEIGHT LOSS AND FEEDING PROBLEMS Much research remains to be done on methods of assisting persons with weight loss and feeding problems. At this point there is some evidence for the following: ●
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Assess all residents for risk factors for nutrition and hydration problems. That assessment should include a focus on medications, pain, and depression; evaluate the level of assistance needed (see Figure 2); and identify the food and fluid preferences of the individual. In persons who can’t express their choices, consultation with family and observation of their behavior during meals may be necessary to determine likes and dislikes. Develop care plans based on these assessments, and implement the care plans using a quality improvement approach. Continuously reevaluate the processes used to ensure the most effective methods are used, as patient characteristics and needs will change over time. At the facility level, provide training in the principles of dementia care and in the specific interventions needed to assist persons with dementia with feeding. This training should include methods for prompting residents as well as preparing the person for the meal (eg, glasses, dentures, hearing aides), making casual conversation, and encouraging staff to ask for help when needed. Among the best references on approaching feeding problems are the free Web resources provided by UCLA’s Boren Center.68 To increase the number of persons available to offer assistance, use the “all hands on deck” approach. Teach other staff in the facility (eg, social workers, occupational therapists, business and office staff) to provide needed assistance at mealtimes. Alternatively, have non-nursing staff perform tasks such as transportation to the dining room, socialization, and meal tray delivery, so that nursing staff can provide feeding assistance. Others who could assist with feeding support and/or socialization at mealtimes, if appropriately trained, include volunteer meal companions and family members.
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Fig. 2. Psychological intervention decision tree for long-term care residents with impaired nutritional intake.
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Provide experienced, facilitative nurse supervision to nursing assistants during mealtimes. This supervision needs to clearly communicate specific needs and interventions for individual residents as well as demonstrate effective interventions. Corrective feedback needs to be respectful of the nursing assistant, support a team philosophy, and create a supportive learning environment. Document carefully the assessment and treatment approaches used by health care team members to address impaired intake and weight loss, and the discussions with and decisions made by patients and families around palliative approaches to nutrition. Hold regular meetings with nursing staff to discuss challenging cases and brainstorm methods for increasing food and fluid intake. For persons who do not respond to interventions such as prompting or snacks between meals, a more intensive assessment by a multidisciplinary team is recommended. Team members may include a nurse, physician, dietitian, activity staff, occupational therapist, and speech therapist. Involvement of the family and the individual are also important. This team approach addresses multiple areas that contribute to poor intake and can result in care plans that meet specific needs.
The implementation of many of these recommendations will likely require a shift in the culture of long-term care Sloane et al 483
facilities. More training and education of staff will likely be required, as well as collaboration with the resident and their families. Ongoing monitoring and reassessment of implementation strategies will be key to ensuring that they are effective. This shift is consistent with the current move to provide more person-directed, individualized care and thus to improve quality-of-life of long-term care facility residents. REFERENCES 1. Centers for Medicare and Medicaid Services, Department of Health and Human Services. Standards for long-term care facilities requirements for states and long term care facilities: quality of care. US Government Printing Office 2006; 42 CFR §483.25(i–j). 2. Pauly L, Stehle P, Volkert D. Nutritional situation of elderly nursing home residents. Z Gerontol Geriatr 2007;40:3–12. 3. Morley JE, Silver AJ. Nutritional issues in nursing home care. Ann Intern Med 1995;123:850 – 859. 4. Amella EJ. Feeding and hydration issues for older adults with dementia. Nurs Clin North Am 2004;39:607– 623. 5. Hudgens J, Langkamp-Henken B. The Mini Nutritional Assessment as an assessment tool in elders in long-term care. Nutr Clin Pract 2004;19: 463– 470. 6. Langkamp-Henken B. Usefulness of the MNA in the long-term and acute-care settings within the United States. J Nutr Health Aging 2006;10:502–506; discussion 506 –509. 7. Wilson MG, Thomas DR, Rubenstein LZ, et al. Appetite assessment: Simple appetite questionnaire predicts weight loss in community-dwelling adults and nursing home residents. Am J Clin Nutr 2005;82:1074 – 1081. 8. Sahyoun NR. Tooth and mouth problems and nutrition among older people. Generations 2004;28:18. 9. Hebling E, Pereira AC. Oral health-related quality of life: A critical appraisal of assessment tools used in elderly people. Gerodontology 2007;24:151–161. 10. Kayser-Jones J, Pengilly K. Dysphagia among nursing home residents. Geriatr Nurs 1999;20:77, 82, 84. 11. Palmer JB, Drennan JC, Baba M. Evaluation and treatment of swallowing impairments. Am Fam Physician 2000;61:2453–2462. 12. Logemann JA, Gensler G, Robbins J, et al. A randomized study of three interventions for aspiration of thin liquids in patients with dementia or Parkinson’s disease. J Speech Lang Hear Res 2008;51:173–183. 13. Huffman GB. Evaluating and treating unintentional weight loss in the elderly. Am Fam Physician 2002;65:640 – 650. 14. Bales CW, Fischer JG, Orenduff MC. Nutritional interventions for aged-related chronic disease. Generations 2004;28:54. 15. Morley JE, Kraenzle D. Causes of weight loss in a community nursing home. J Am Geriatr Soc 1994;42:583–585. 16. Cabrera MA, Mesas AE, Garcia AR, de Andrade SM. Malnutrition and depression among community-dwelling elderly people. J Am Med Dir Assoc 2007;8:582–584. 17. Robertson R, Montagnini M. Geriatric failure to thrive. Am Fam Physician 2004;70:343–350. 18. Rigler SK, Webb MJ, Redford L, et al. Weight outcomes among antidepressant users in nursing facilities. J Am Geriatr Soc 2001;49: 49 –55. 19. Fawcett J, Barkin RL. Review of the results from clinical studies on the efficacy, safety and tolerability of mirtazapine for the treatment of patients with major depression. J Affect Disord 1998;51:267–285. 20. Malone M. Medications associated with weight gain. Ann Pharmacother 2005;39:2046 –2055. 21. Wilson MG, Philpot C, Morley JE. Anorexia of aging in long-term care: Is dronabinol an effective appetite stimulant? A pilot study. J Nutr Health Aging 2007;11:195–198. 22. Volicer L, Stelly M, Morris J, et al. Effects of dronabinol on anorexia and disturbed behavior in patients with Alzheimer’s disease. Int J Geriatr Psychiatry 1997;12:913–919. 484 Sloane et al
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46. Mitchell SL, Buchanan JL, Littlehale S, Hamel MB. Tube-feeding versus hand-feeding nursing home residents with advanced dementia: A cost comparison. J Am Med Dir Assoc 2004;5:S22–29. 47. Mitchell SL, Teno JM, Roy J, et al. Clinical and organizational factors associated with feeding tube use among nursing home residents with advanced cognitive impairment. JAMA 2003;290:73– 80. 48. Schnelle JF, Ouslander JG, Osterweil D, Blumenthal S. Total quality management: Administrative and clinical applications in nursing homes. J Am Geriatr Soc 1993;41:1259 –1266. 49. Evans BC, Crogan NL. Quality improvement practices: Enhancing quality of life during mealtimes. J Nurses Staff Dev 2001;17:131–136. 50. Simmons S, Alessi C, Schnelle J. An intervention to increase fluid intake in nursing home residents: Prompting and preference compliance. J Am Geriatr Soc 2001;49:926 –933. 51. Young K, Greenwood C. Shift in diurnal feeding patterns in nursing home residents with Alzheimer’s disease. J Gerontol A Biol Sci Med Sci 2001;56:M700 –706. 52. Altus DE, Engelman KK, Mathews RM. Using family-style meals to increase participation and communication in persons with dementia. J Gerontol Nurs 2002;28:47–53. 53. Van Ort S, Phillips L. Feeding nursing home residents with Alzheimer’s disease. Geriatr Nurs 1992;13:249. 54. Pelletier C. What do certified nurse assistants actually know about dysphagia and feeding nursing home residents? Am J Speech Lang Pathol 2004;13:99 –113. 55. Sanders H. Nutrition management in long-term care. J Nutr Elder 1990;9:69 –74. 56. Simmons S, Osterweil D, Schnelle J. Improving food intake in nursing home residents with feeding assistance: A staffing analysis. J Gerontol A Biol Sci Med Sci 2001;56:M790 –94.
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