- Email: [email protected]
Practical approach to nutritional support in nursing home
Abstracts / Clinical Nutrition ESPEN 14 (2016) 42e57
lot of work ahead of them, trying to improve the nourishment state of their residents. Keywords: residential home, nutritional evaluation, practical approach References 1. Letno poro cilo o delu 2015 in plan dela 2016. Skofja Loka: Center slepih, slabovidnih in starejsih Skofja Loka, 2016. 2. Priporo cila za prehransko obravnavo bolnikov v bolnisnicah in starostnikov v domovih za starejse ob cane. Ljubljana: Ministrstvo za zdravje, 2008. 3. Blenkus M G, Stojanovi c Jerkovi c O. Prehrana in telesna dejavnost za zdravje pri starejsih- pregled stanja. Ljubljana: Institut za varovanje zdravja Republike Slovenije, 2010. PRACTICAL APPROACH TO NUTRITIONAL SUPPORT IN NURSING HOME Damjan Zelenik 1, Tatjana Persuh RN 2, Taja Jordan MD 3. 1 DSO Hrastnik, Slovenia; 2 DSO Danice Vogrinec Maribor, Slovenia; 3 Institute of Oncology, Ljubljana, Slovenia E-mail addresses: [email protected] (T. Jordan).
Abstract The number of elderly people in our population is increasing. Our job, as a society, is to respond to specific needs of the elderly and to solve them in appropriate ways. Part of the elderly population needs to be taken care of in various institutions, such as nursing homes. Nursing homes provide all types of assistance, to replace or complement functions of home and family. They provide the relevant conditions of accommodation, health care and organized food supply. Nursing homes are faced with a very heterogeneous population of residents, which is reflected in highly heterogeneous and specific nutritional needs. More often than in the past, the elderly decide for admission into nursing home only after they have become very sick and need nutritional support. Regarding the gender, the women predominate. People usually decide to be a part of a local nursing home, where they expect a local food supply. This can significantly affect their satisfaction. Nursery homes are obliged to provide nutrition, which is appropriate for the age and health conditions of their residents. Nutritional care of the elderly in a residential setting is optimal when the meals are balanced, provide adequate nutrient and energy intakes, are safe, tasteful and fulfilling. The food service network is responsible for planning, organizing and conducting nutritional support of residents and other clients. The organizational and planning aspects are overseen by heads of nutritional services - organizers of nutrition, who are employed in all nursing homes, even though the job norms are still not identified. In recent years, we have seen employment of workers with a VI. and VII. levels of professional education in the field of food technology, catering and healthcare. The personnel which is directly responsible for the preparation of food are specifically trained (employees have professional qualifications from relevant study programs, except in the field of catering, where this is no longer needed) and are additionally trained to prepare meals that adhere to specific dietary needs by a national qualification. Employees in the field of nutritional care for the elderly are connected in a network »Aktiv prehranskih delavcev« that operates under Association of Social Institutions of Slovenia. The following guidelines are being strictly followed for the purpose of preparing meals: the “Recommendations for nutritional support of patients in hospitals and the elderly in nursing homes” (Ministry of Health, 2008), “Practicum of menus for healthy nutrition of patients in hospitals and the elderly in nursery homes” (Ministry of Health, 2008) and the reference values for the intake of nutrients. Expert instructions and guidelines are followed for composing special dietary menus. Food safety is based on HACCP principles. During the process of selecting and ordering of food ingredients, we are partially restricted by public tender. Although this can offer some advantage, unfortunately there are some cases in which this situation provides the opportunity for suppliers of lower quality foods. The proportion of organic and locally grown foods in nursery homes is increasing by creating a system of green public procurement and direct procurement from the local food producers. Nursery homes are strongly linked to their local environment. In addition to other services, they provide nutrition services for the local population,
53
which usually means the delivery of meals to the senior citizens. In smaller towns, nursery homes are the only ones who can provide meals for different dietary requirements, in addition to the usual menus. It is important to emphasize the importance of education of the local population regarding healthy nutrition and the practical preparation of healthier food. When planning nutritional support for the elderly and/or a resident of a nursery home, who is nutritionally compromised or malnourished, we are faced with many problems. Many residents living in nursery homes are severely ill. These conditions are usually chronic and have evolved to an advanced stage. These patients are often prescribed many different types of medication. All this affects their metabolic state and therefore their nutritional status. In addition, there are many other problems, which are often presented in the elderly, such as anorexia, swallowing disorders, lack of teeth, dementia and depression. These factors can have a significant impact on the nutritional status of the elderly, who are at higher risk of malnutrition, sarcopenia and cachexia. Another important aspect of planning for nursing home nutrition is taking into consideration a population of young adults, who also suffer from certain medical or other conditions which affect their nutritional status. The goal of nutritional support for this group is mainly to maintain their independence for as long as possible and to take advantage of their preserved abilities to perform basic activities, which include eating. For this group of residents, it is often necessary to prepare individual dietary plans. The conditions we are facing with are mainly swallowing disorders, sarcopenia and cachexia, which are often the cause for admission as a result of advanced-stage neurological disease (i.e. multiple sclerosis, muscular dystrophy, Huntington's disease, MLS, etc.), where adequate care in the home environment was no longer possible. Most residents in nursery homes enjoy simple and healthy meals. About 40% of residents need a special diet. Most of these include diets for diabetics, patients with gallbladder or stomach diseases, or modified consistency diets in case of the problems with swallowing or chewing. In the case of malnutrition, residents get adequate nutritional support. Nutritional support is ensured by an appropriate selection of nutrients, the introduction of additional meals and oral nutritional supplements. With patients who are suffering from malnutrition or are at nutritional risk, in order to maintain or improve the nutritional status, we use oral nutritional supplements to increase the intake of energy, protein and micronutrients. Special attention is given to residents who have wounds or pressure sores, as an appropriate nutritional support plays an important role in the prevention and healing of wounds and pressure sores. Oral nutritional supplements, especially those with high content of proteins and other nutrients that affect wound healing, have become the standard treatment of residents with wounds or pressure sores. According to the expert recommendations, the tube fed residents are offered industrially prepared (enteral) nutrition. Conclusion Malnutrition has many causes. Only when everyone responsible for nutritional support of the elderly and ill individuals (family members, doctors, nurses, dieticians, etc.) recognizes the problem in its early stages and reacts accordingly, will the affected receive adequate nutritional support. It is essential that all professional groups work closely together to solve the problem of malnutrition. We must realize that despite the well-designed nutritional support we are not reaching our goal. The reasons for this are severe health conditions, many diseases, apathy and unwillingness of residents to participate, but mostly residents with irreversible cachexia, resulting from an incurable disease, age and other factors. This means that despite using all measures, we cannot improve the nutritional status in these cases. Despite an increasing amount of knowledge, there are still obstacles to achieving these goals, many of them subjective. Sadly, there are still some employees, part of them in leading positions, who are not willing to change, do not trust or follow professional guidelines, and do not present with the wisdom and motivation to include novelties and positive experiences of their colleagues into everyday practice. Keywords: residential homes, malnutrition, nutritional care, practical aproach References 1. Priporo cila za prehransko obravnavo bolnikov v bolnisnicah in starostnikov v domovih za starejse ob cane, Ljubljana: Ministrstvo za zdravje RS; 2008
54
Abstracts / Clinical Nutrition ESPEN 14 (2016) 42e57
2. Rotovnik Kozjek N, Vpliv posameznih hranil na celjenje rane. V: Vilar V, Prehranska podpora pacientov s kroni cno rano. Ljubljana:drustvo za oskrbo ran Slovenije- DORS, 2010. 3. Sedej I, Vloga klini cnega dietetika pri prehranski podpori bolnika z motnjami po ziranja V: 4. Petkovsek Gregorin R. Motnje po ziranja in na cini hranjenja: zbornik predavanj. Lasko: Zbornica zdravstvene in babiske nege Slovenije - Zveza strokovnih drustev medicinskih sester, babic in zdravstvenih tehnikov Slovenije- Sekcija medicinskih sester in zdravstvenih tehnikov v rehabilitaciji in zdraviliski dejavnosti; 2012 5. Sedej I, Zupanc Isoski V, Bizjak M. Prehranska podpora bolnika po mo zganski kapi in disfagi cne diete. V: Zupanc Isoski V, Pra znikar A, eds. Disfagija in mo zganska kap. Ljubljana: Nevroloska klinika, UKC, 2011: 123e40 6. Zemva N, Motnje po ziranja. Dosegljivo na: http://www.zdruzenjecvb. com/strokovni-clanki.html (10.13.2016). CHALLENGES FOR DIETITIANS IN NUTRITIONAL SUPPORT OF ELDERLY Denis Mlakar Mastnak RN, RD, Mila Ter celj RD. Institute of Oncology Ljubljana, Slovenia E-mail address: [email protected] (D.M. Mastnak).
Abstract Introduction A dietitian as a member of multidisciplinary team plays a key role in the prevention of malnutrition and nutritional support in the elderly. It is important that dietitians play this role actively in all levels of nutritional support, in political, in educational, in clinical practice and at the administrative level. Nutrition support of the elderly, challenges for clinical dietetics Challenges for clinical dietician in the nutritional treatment of the elderly include five areas that are presented below. Factors bound to the patient In hospitals and nursing homes is particularly challenging early identification of those factors that significantly affect the increased risk of malnutrition in the elderly and the progression of sarcopenia. These factors are as follows: modified energy-savings needs; chronic diseases; consumption of medicinal products; nutritional problems; the ability for self-feeding; physical capacity and physical activity; cognitive skills; economic and social circumstances, and others. Institutional factors In addition to the risk factors related to the patient the importance of recognizing and addressing factors related to institutional circumstances such as: Access to individual nutritional treatment and counseling; Food supply, which is consistent with nutritional recommendations for elderly; A diet that is high quality and varied, adapted to elderly taste and abilities for independent eating; Unnecessary dietary restrictions due to medical diagnostic procedures, unsubstantiated insufficient energy dense and nutritious food, etc. Identifying malnutrition Although Mini Nutrition Assessment is a tool for nutritional screening, specifically prepared for use in the elderly over 65 years, the tool with which we can accuratly evaluate the nutritional status in the elderly still doesn’t exists. Thus, in identifying malnutrition, a dietitian cannot simply rely on a screening tool, he/she always must carry out clinical judgment for which he/she requires skills, experience and qualifications. Assessment of nutritional status and dietary diagnosis Nutritional assessment is a diagnostic process used to assess the nutritional status of the elderly. Its ultimate objective is to determine the diagnosis of malnutrition. The concept of malnutrition in itself does not identify its cause. But dietitians have to plan an effective nutritional therapy that is focused on the cause of malnutrition. Therefore, nutrition
diagnosis must identify the nutritional problem, its causes and symptoms. Dietitians therefore are challenged to identify the causes of malnutrition, which may be different. Nutritional therapy and counseling A special challenge for clinical dietician in the nutritional therapy and nutritional counselling, which is a central part of the nutritional support in the elderly, is the use of effective nutrition and other strategies (motivational, educational, psychological, social, etc.). Also, the implementation of evidence-based nutritional therapy in practice is a challenge, because knowledge in this field is developing rapidly and there are obstacles (human, institutional, economic, et al.), which can slow down or hinder the use of the new knowledge in the practice of nutritional support. Conclusion Since the practice of clinical nutritional support in the Slovenian public health system has not yet been formally introduced and standardized, gaining relevant clinical work experience and skills is becoming a special challenge for dietitians. Active political engagement of dietitians is also an important challenge by which we can achieve that nutritional support of elderly will be present at all three levels of health care system. Keywords: clinical dietician, nutrition of the elderly, nutritional treatment References pez MD, García VP, Estrella JD, Gonza lez AS, Vilardell NB, 1. Abizanda P, Lo Torres KA, Effects of an Oral Nutritional Supplementation Plus Physical Exercise Intervention on the Physical Function, Nutritional Status, and Quality of Life in Frail Institutionalized Older Adults: The ACTIVNES Study. J Am Med Dir Assoc. 2015; 16(5): 439.e9-439.e16. 2. Ahmed T, Haboubi N, Assessment and management of nutrition in older people and its importance to health. Clin Interv Aging. 2010; 9(5): 207-216. 3. Allen VJ, Methven L, Gosney MA, Use of nutritional complete supplement in older adults with dementia: systematic review and meta-analysis of clinical outcomes. Clin Nutr. 2013;32(6): 950-957 4. Beck AM, Gøgsig Christensen A, Stenbæk Hansen B, Damsbo-Svendsen S, Kreinfeldt Skovgaard Møller T, Boll Hansen E, Keiding H, Study protocol: cost-effectiveness of multidisciplinary nutritional support for undernutrition in older adults in nursing home and home-care: cluster randomized controlled trial. Nutr J. 2014;13 (86): 2-8. 5. Bernstein M, Munoz N. Position of the Academy of Nutrition and Dietetics: food and nutrition for older adults: promoting health and wellness. J Acad Nutr Diet 2012;112(8):1255-1277. 6. Borg S, Groot LCPGM, Mijnarends DM, Vries JHM, Verlaan S, Meijboom S, Luiking YC, Schols JMGA, Differences in Nutrient Intake and Biochemical Nutrient Status Between Sarcopenic and Nonsarcopenic Older Adults e Results From Maastricht Sarcopenia Study. J Am Med Dir Assoc 2016; (15) 1- 9. 7. Bowman, S. Low economic status is associated with suboptimal intakes of nutritious foods by adults in the National Health and Nutrition Examination Survey 1999-2002. Nutrition research 2007;27(9); 515-523. n S, Cabre M, Monteis R, Roca M, Palomera E, Serra-Prat M, Rofes L, 8. Carrio P, Oropharyngeal dysphagia is a prevalent risk factor for malnutrition Clave in a cohort of older patients admitted with an acute disease to a general hospital. Clin Nutr. 2015; 34(3): 436-442. 9. Cederholm T, Bosaeus I, Barazzoni R, Bauer J, Van Gossum A, Klek S, Muscaritoli M, Nyulasi I, Ockenga J, Schneider SM, de van der Schueren MA, Singer P, Diagnostic criteria for malnutrition- An ESPEN Consensus Statement. Clin Nutr. 2015; 34(3): 335-340. 10. Deutz NE, Matheson EM, Matarese LE, Luo M, Baggs GE, Nelson JL, Hegazi RA, Tappenden KA, Ziegler TR; Readmission and mortality in malnourished, older, hospitalized adults treated with a specialized oral nutritional supplement: A randomized clinical trial. Clin Nutr. 2016; 35(1): 18-26. 11. Dorner B, Posthauer ME. Nutrition’s Role in Sarcopenia Prevention. Today’s Dietitian 2012; 14 (9): 62. 12. European Federation of the associations of dietitians (EFAD). Briefing paper on the role of the dietetitian in the prevention and management of nutrition-related disease in older adults; 2013; 1-15 13. Landi F, Onder G, Russo A, Liperoti R, Tosato M, Martone AM, Capoluongo E, Bernabei R. Calf circumference, frailty and physical performance among older adults living in the community. Clin Nutr 2014;33(3):539-44. 14. McNaughton SA, Crawford D, Kylie Ball K, Salmon J. Understanding determinants of nutrition, physical activity and quality of life among older
lot of work ahead of them, trying to improve the nourishment state of their residents. Keywords: residential home, nutritional evaluation, practical approach References 1. Letno poro cilo o delu 2015 in plan dela 2016. Skofja Loka: Center slepih, slabovidnih in starejsih Skofja Loka, 2016. 2. Priporo cila za prehransko obravnavo bolnikov v bolnisnicah in starostnikov v domovih za starejse ob cane. Ljubljana: Ministrstvo za zdravje, 2008. 3. Blenkus M G, Stojanovi c Jerkovi c O. Prehrana in telesna dejavnost za zdravje pri starejsih- pregled stanja. Ljubljana: Institut za varovanje zdravja Republike Slovenije, 2010. PRACTICAL APPROACH TO NUTRITIONAL SUPPORT IN NURSING HOME Damjan Zelenik 1, Tatjana Persuh RN 2, Taja Jordan MD 3. 1 DSO Hrastnik, Slovenia; 2 DSO Danice Vogrinec Maribor, Slovenia; 3 Institute of Oncology, Ljubljana, Slovenia E-mail addresses: [email protected] (T. Jordan).
Abstract The number of elderly people in our population is increasing. Our job, as a society, is to respond to specific needs of the elderly and to solve them in appropriate ways. Part of the elderly population needs to be taken care of in various institutions, such as nursing homes. Nursing homes provide all types of assistance, to replace or complement functions of home and family. They provide the relevant conditions of accommodation, health care and organized food supply. Nursing homes are faced with a very heterogeneous population of residents, which is reflected in highly heterogeneous and specific nutritional needs. More often than in the past, the elderly decide for admission into nursing home only after they have become very sick and need nutritional support. Regarding the gender, the women predominate. People usually decide to be a part of a local nursing home, where they expect a local food supply. This can significantly affect their satisfaction. Nursery homes are obliged to provide nutrition, which is appropriate for the age and health conditions of their residents. Nutritional care of the elderly in a residential setting is optimal when the meals are balanced, provide adequate nutrient and energy intakes, are safe, tasteful and fulfilling. The food service network is responsible for planning, organizing and conducting nutritional support of residents and other clients. The organizational and planning aspects are overseen by heads of nutritional services - organizers of nutrition, who are employed in all nursing homes, even though the job norms are still not identified. In recent years, we have seen employment of workers with a VI. and VII. levels of professional education in the field of food technology, catering and healthcare. The personnel which is directly responsible for the preparation of food are specifically trained (employees have professional qualifications from relevant study programs, except in the field of catering, where this is no longer needed) and are additionally trained to prepare meals that adhere to specific dietary needs by a national qualification. Employees in the field of nutritional care for the elderly are connected in a network »Aktiv prehranskih delavcev« that operates under Association of Social Institutions of Slovenia. The following guidelines are being strictly followed for the purpose of preparing meals: the “Recommendations for nutritional support of patients in hospitals and the elderly in nursing homes” (Ministry of Health, 2008), “Practicum of menus for healthy nutrition of patients in hospitals and the elderly in nursery homes” (Ministry of Health, 2008) and the reference values for the intake of nutrients. Expert instructions and guidelines are followed for composing special dietary menus. Food safety is based on HACCP principles. During the process of selecting and ordering of food ingredients, we are partially restricted by public tender. Although this can offer some advantage, unfortunately there are some cases in which this situation provides the opportunity for suppliers of lower quality foods. The proportion of organic and locally grown foods in nursery homes is increasing by creating a system of green public procurement and direct procurement from the local food producers. Nursery homes are strongly linked to their local environment. In addition to other services, they provide nutrition services for the local population,
53
which usually means the delivery of meals to the senior citizens. In smaller towns, nursery homes are the only ones who can provide meals for different dietary requirements, in addition to the usual menus. It is important to emphasize the importance of education of the local population regarding healthy nutrition and the practical preparation of healthier food. When planning nutritional support for the elderly and/or a resident of a nursery home, who is nutritionally compromised or malnourished, we are faced with many problems. Many residents living in nursery homes are severely ill. These conditions are usually chronic and have evolved to an advanced stage. These patients are often prescribed many different types of medication. All this affects their metabolic state and therefore their nutritional status. In addition, there are many other problems, which are often presented in the elderly, such as anorexia, swallowing disorders, lack of teeth, dementia and depression. These factors can have a significant impact on the nutritional status of the elderly, who are at higher risk of malnutrition, sarcopenia and cachexia. Another important aspect of planning for nursing home nutrition is taking into consideration a population of young adults, who also suffer from certain medical or other conditions which affect their nutritional status. The goal of nutritional support for this group is mainly to maintain their independence for as long as possible and to take advantage of their preserved abilities to perform basic activities, which include eating. For this group of residents, it is often necessary to prepare individual dietary plans. The conditions we are facing with are mainly swallowing disorders, sarcopenia and cachexia, which are often the cause for admission as a result of advanced-stage neurological disease (i.e. multiple sclerosis, muscular dystrophy, Huntington's disease, MLS, etc.), where adequate care in the home environment was no longer possible. Most residents in nursery homes enjoy simple and healthy meals. About 40% of residents need a special diet. Most of these include diets for diabetics, patients with gallbladder or stomach diseases, or modified consistency diets in case of the problems with swallowing or chewing. In the case of malnutrition, residents get adequate nutritional support. Nutritional support is ensured by an appropriate selection of nutrients, the introduction of additional meals and oral nutritional supplements. With patients who are suffering from malnutrition or are at nutritional risk, in order to maintain or improve the nutritional status, we use oral nutritional supplements to increase the intake of energy, protein and micronutrients. Special attention is given to residents who have wounds or pressure sores, as an appropriate nutritional support plays an important role in the prevention and healing of wounds and pressure sores. Oral nutritional supplements, especially those with high content of proteins and other nutrients that affect wound healing, have become the standard treatment of residents with wounds or pressure sores. According to the expert recommendations, the tube fed residents are offered industrially prepared (enteral) nutrition. Conclusion Malnutrition has many causes. Only when everyone responsible for nutritional support of the elderly and ill individuals (family members, doctors, nurses, dieticians, etc.) recognizes the problem in its early stages and reacts accordingly, will the affected receive adequate nutritional support. It is essential that all professional groups work closely together to solve the problem of malnutrition. We must realize that despite the well-designed nutritional support we are not reaching our goal. The reasons for this are severe health conditions, many diseases, apathy and unwillingness of residents to participate, but mostly residents with irreversible cachexia, resulting from an incurable disease, age and other factors. This means that despite using all measures, we cannot improve the nutritional status in these cases. Despite an increasing amount of knowledge, there are still obstacles to achieving these goals, many of them subjective. Sadly, there are still some employees, part of them in leading positions, who are not willing to change, do not trust or follow professional guidelines, and do not present with the wisdom and motivation to include novelties and positive experiences of their colleagues into everyday practice. Keywords: residential homes, malnutrition, nutritional care, practical aproach References 1. Priporo cila za prehransko obravnavo bolnikov v bolnisnicah in starostnikov v domovih za starejse ob cane, Ljubljana: Ministrstvo za zdravje RS; 2008
54
Abstracts / Clinical Nutrition ESPEN 14 (2016) 42e57
2. Rotovnik Kozjek N, Vpliv posameznih hranil na celjenje rane. V: Vilar V, Prehranska podpora pacientov s kroni cno rano. Ljubljana:drustvo za oskrbo ran Slovenije- DORS, 2010. 3. Sedej I, Vloga klini cnega dietetika pri prehranski podpori bolnika z motnjami po ziranja V: 4. Petkovsek Gregorin R. Motnje po ziranja in na cini hranjenja: zbornik predavanj. Lasko: Zbornica zdravstvene in babiske nege Slovenije - Zveza strokovnih drustev medicinskih sester, babic in zdravstvenih tehnikov Slovenije- Sekcija medicinskih sester in zdravstvenih tehnikov v rehabilitaciji in zdraviliski dejavnosti; 2012 5. Sedej I, Zupanc Isoski V, Bizjak M. Prehranska podpora bolnika po mo zganski kapi in disfagi cne diete. V: Zupanc Isoski V, Pra znikar A, eds. Disfagija in mo zganska kap. Ljubljana: Nevroloska klinika, UKC, 2011: 123e40 6. Zemva N, Motnje po ziranja. Dosegljivo na: http://www.zdruzenjecvb. com/strokovni-clanki.html (10.13.2016). CHALLENGES FOR DIETITIANS IN NUTRITIONAL SUPPORT OF ELDERLY Denis Mlakar Mastnak RN, RD, Mila Ter celj RD. Institute of Oncology Ljubljana, Slovenia E-mail address: [email protected] (D.M. Mastnak).
Abstract Introduction A dietitian as a member of multidisciplinary team plays a key role in the prevention of malnutrition and nutritional support in the elderly. It is important that dietitians play this role actively in all levels of nutritional support, in political, in educational, in clinical practice and at the administrative level. Nutrition support of the elderly, challenges for clinical dietetics Challenges for clinical dietician in the nutritional treatment of the elderly include five areas that are presented below. Factors bound to the patient In hospitals and nursing homes is particularly challenging early identification of those factors that significantly affect the increased risk of malnutrition in the elderly and the progression of sarcopenia. These factors are as follows: modified energy-savings needs; chronic diseases; consumption of medicinal products; nutritional problems; the ability for self-feeding; physical capacity and physical activity; cognitive skills; economic and social circumstances, and others. Institutional factors In addition to the risk factors related to the patient the importance of recognizing and addressing factors related to institutional circumstances such as: Access to individual nutritional treatment and counseling; Food supply, which is consistent with nutritional recommendations for elderly; A diet that is high quality and varied, adapted to elderly taste and abilities for independent eating; Unnecessary dietary restrictions due to medical diagnostic procedures, unsubstantiated insufficient energy dense and nutritious food, etc. Identifying malnutrition Although Mini Nutrition Assessment is a tool for nutritional screening, specifically prepared for use in the elderly over 65 years, the tool with which we can accuratly evaluate the nutritional status in the elderly still doesn’t exists. Thus, in identifying malnutrition, a dietitian cannot simply rely on a screening tool, he/she always must carry out clinical judgment for which he/she requires skills, experience and qualifications. Assessment of nutritional status and dietary diagnosis Nutritional assessment is a diagnostic process used to assess the nutritional status of the elderly. Its ultimate objective is to determine the diagnosis of malnutrition. The concept of malnutrition in itself does not identify its cause. But dietitians have to plan an effective nutritional therapy that is focused on the cause of malnutrition. Therefore, nutrition
diagnosis must identify the nutritional problem, its causes and symptoms. Dietitians therefore are challenged to identify the causes of malnutrition, which may be different. Nutritional therapy and counseling A special challenge for clinical dietician in the nutritional therapy and nutritional counselling, which is a central part of the nutritional support in the elderly, is the use of effective nutrition and other strategies (motivational, educational, psychological, social, etc.). Also, the implementation of evidence-based nutritional therapy in practice is a challenge, because knowledge in this field is developing rapidly and there are obstacles (human, institutional, economic, et al.), which can slow down or hinder the use of the new knowledge in the practice of nutritional support. Conclusion Since the practice of clinical nutritional support in the Slovenian public health system has not yet been formally introduced and standardized, gaining relevant clinical work experience and skills is becoming a special challenge for dietitians. Active political engagement of dietitians is also an important challenge by which we can achieve that nutritional support of elderly will be present at all three levels of health care system. Keywords: clinical dietician, nutrition of the elderly, nutritional treatment References pez MD, García VP, Estrella JD, Gonza lez AS, Vilardell NB, 1. Abizanda P, Lo Torres KA, Effects of an Oral Nutritional Supplementation Plus Physical Exercise Intervention on the Physical Function, Nutritional Status, and Quality of Life in Frail Institutionalized Older Adults: The ACTIVNES Study. J Am Med Dir Assoc. 2015; 16(5): 439.e9-439.e16. 2. Ahmed T, Haboubi N, Assessment and management of nutrition in older people and its importance to health. Clin Interv Aging. 2010; 9(5): 207-216. 3. Allen VJ, Methven L, Gosney MA, Use of nutritional complete supplement in older adults with dementia: systematic review and meta-analysis of clinical outcomes. Clin Nutr. 2013;32(6): 950-957 4. Beck AM, Gøgsig Christensen A, Stenbæk Hansen B, Damsbo-Svendsen S, Kreinfeldt Skovgaard Møller T, Boll Hansen E, Keiding H, Study protocol: cost-effectiveness of multidisciplinary nutritional support for undernutrition in older adults in nursing home and home-care: cluster randomized controlled trial. Nutr J. 2014;13 (86): 2-8. 5. Bernstein M, Munoz N. Position of the Academy of Nutrition and Dietetics: food and nutrition for older adults: promoting health and wellness. J Acad Nutr Diet 2012;112(8):1255-1277. 6. Borg S, Groot LCPGM, Mijnarends DM, Vries JHM, Verlaan S, Meijboom S, Luiking YC, Schols JMGA, Differences in Nutrient Intake and Biochemical Nutrient Status Between Sarcopenic and Nonsarcopenic Older Adults e Results From Maastricht Sarcopenia Study. J Am Med Dir Assoc 2016; (15) 1- 9. 7. Bowman, S. Low economic status is associated with suboptimal intakes of nutritious foods by adults in the National Health and Nutrition Examination Survey 1999-2002. Nutrition research 2007;27(9); 515-523. n S, Cabre M, Monteis R, Roca M, Palomera E, Serra-Prat M, Rofes L, 8. Carrio P, Oropharyngeal dysphagia is a prevalent risk factor for malnutrition Clave in a cohort of older patients admitted with an acute disease to a general hospital. Clin Nutr. 2015; 34(3): 436-442. 9. Cederholm T, Bosaeus I, Barazzoni R, Bauer J, Van Gossum A, Klek S, Muscaritoli M, Nyulasi I, Ockenga J, Schneider SM, de van der Schueren MA, Singer P, Diagnostic criteria for malnutrition- An ESPEN Consensus Statement. Clin Nutr. 2015; 34(3): 335-340. 10. Deutz NE, Matheson EM, Matarese LE, Luo M, Baggs GE, Nelson JL, Hegazi RA, Tappenden KA, Ziegler TR; Readmission and mortality in malnourished, older, hospitalized adults treated with a specialized oral nutritional supplement: A randomized clinical trial. Clin Nutr. 2016; 35(1): 18-26. 11. Dorner B, Posthauer ME. Nutrition’s Role in Sarcopenia Prevention. Today’s Dietitian 2012; 14 (9): 62. 12. European Federation of the associations of dietitians (EFAD). Briefing paper on the role of the dietetitian in the prevention and management of nutrition-related disease in older adults; 2013; 1-15 13. Landi F, Onder G, Russo A, Liperoti R, Tosato M, Martone AM, Capoluongo E, Bernabei R. Calf circumference, frailty and physical performance among older adults living in the community. Clin Nutr 2014;33(3):539-44. 14. McNaughton SA, Crawford D, Kylie Ball K, Salmon J. Understanding determinants of nutrition, physical activity and quality of life among older