On Friday, August 25, 2000 from 1:00-3:00p.m. there was a HCFA satellite broadcast that discussed the most current information related to nutrition and hydration in the long-term care setting. The following information summarizes the main points that are relevant to all levels of staff involved in resident care.

• In long term care there are more concerns related to weight loss than weight gain.
  
• The cause of weight loss in your residents can be the result of existing known medical conditions or dietary and social factors.
  
• Examples of known medical conditions include: history of stroke, heart disease, hyper/hypothyroid disease, diabetes, dental problems, difficulty swallowing or digesting foods, conditions that require the resident receiving a large number of medications. There are other medical conditions not listed that can cause weight loss.
  
• Examples of dietary factors include: residents that are placed on diets that limit salt, sugar, and fat. These limitations can cause your residents to lose weight because the food tastes bland to them and they will not eat it. Research has shown that even though dietary limitations are ordered because of a resident's medical condition they often do more harm than good, because the resident will stop eating.
  
• Other dietary restrictions that can cause a weight loss in your resident involve calorie restrictions. Restricting calories in your residents should be done very carefully due to the multiple factors that can cause a long term resident to experience a general decrease in food intake. Fluid restrictions can also result in weight loss. Restrictions in fluid can be the cause of[much] misery for your residents. If the resident has a medical condition that requires that his or her fluid be monitored and that same resident has had adequate output after taking "water pills," then you don't have to worry as much about the amount of fluid you give.
  
• Social factors that can cause a weight loss in your residents are many. The residents eating environment should be "home like." Room temperature, noise level, and resident positioning at the table are things to be considered. In addition placing cognitively impaired residents with poor "eating habits" with residents who do not have problems managing their food intake can result in poor food intake for your residents that are not cognitively impaired and more independent with their eating skills.
  
• Honoring food preferences is also a social factor to think about in terms of decreasing weight loss in your residents. It would be helpful to know your resident's food preferences (likes or dislikes) often done through careful assessment. Another consideration is the resident's cultural background. If your resident is served food that he or she does not typically eat, there is an increased chance of the resident either not eating the meal or not eating much of the meal.
  
• There are several factors that can put your resident at risk for weight loss that is part of the resident's history when he or she was admitted to your facility. Examples of these factors include:
  
  
  • A prior history of weight loss
  • Functional disabilities such as stroke, blindness, fractures of arms/hands, dental disease, uncontrolled body "shaking". Difficulty swallowing, diabetes, constipation, and diarrhea are additional examples of preexisting functional disabilities in your residents.
  • Illness which requires your resident to take several different medications.
    
    

• There are other risks factors that are too numerous to identify.
  

• There are some things that can be done to help improve the food intake of residents with preexisting functional disabilities, thereby decreasing the chances of weight loss. These helpful measures include:
• • Putting residents with a history of stroke (i.e. paralysis) and upper body fractures on a feeding program.
  • Telling blind residents how their food is placed on the tray before they begin eating.
  • Looking in your residents mouths to make sure they do not have any problems with their dentures or any painful gums.
  • Residents who experience "shaking" of their arms, hands, etc. should be served foods that are easy to grasp.
  • Observe for signs of constipation or diarrhea in your resident. Constipation can result in a decreased appetite, and diarrhea prevents food from being absorbed.
  • Observe for side effects of medications, especially when you know your resident is taking a lot of different medications on a daily basis.
    
    
• Your resident can have more than one illness which causes him or her to lose weight.
  
  
  • If your resident has dementia and /or depression eating may not be important to that resident.
  • Infections such as bladder, bone, or kidney can result in the need for more protein and calories in your resident, and if food intake is not adequate a weight loss can be the result.
  • Residents that "wander" aimlessly around your facility frequently burn a lot a calories which can result in a weight loss.
  • Residents that have multiple illnesses such as uncontrolled diabetes, end stage kidney disease, and rheumatoid arthritis are at a high risk for weight loss.

  
   

There has not been a standard criteria established for the diagnosis of malnutrition, therefore the literature has utilized clinical characteristics and complications as a way to assess if a resident is malnourished or not. Examples of clinical characteristics and complications include the following:

Clinical Characteristics

• Recent weight loss
• Anorexia (loss of appetite)
• Loss of fat
• Loss of muscle tissues
• Hypoalbuminemia
  
  

Complications of malnutrition

• Recurrent infections
• Pressure ulcers that fail to heal
• Colonization (examples Methicillin-Resistant Staphyloccus Aureus (MRSA), Vancomycin-Resistent Enterococcus (VRE) etc.
• Body mass index of 18 or less (problem with this measurement is there are frequently problems obtaining resident's height).
• Prealbumin/Albumin (please note that prealbumin is not a good indicator of protein metabolism)
• Total lymphocyte count
• Anemia
• Hypercholesterolemia
  
  

The issue of dehydration is important when assessing the nutritional status of your resident. Listed below are some of the warning signs of dehydration to observe:

• Resident drinks less than 6 cups of fluid per day or needs help drinking or swallowing.
• Resident has dry mouth or cracked lips
• Dark urine
• Resident experiences an increased number of fall and recurrent infections
  

The issue of tube feedings in end stage dementia patients was identified as one of "ethics" as opposed to nutrition in this presentation.

Interdisciplinary assessment to determine the cause of weight loss as well as the cause of end state dementia is very important. Members of the interdisciplinary team should include:

• Dietitian (could provide calorie count)
• Nursing
• Pharmacist
• Social worker
• Occupational therapist
  
  

There are 2 types of weight loss identified for long term care residents:

• Intended (unavoidability is not an issue)
• Unintended weight loss
  
  

Under the unintended weight loss category several factors were identified that influenced a residents inability to eat. Dr. George Taler labeled these "anorexogenic conditions." Examples of these conditions were listed as:

• Demential/Delirium
• Depression
• Pain(especially oral)
• Constipation
• Polypharmacy (i.e. receiving several medications)
• Chronic infections
• End stage disease
  
  

If you have residents in your facility in your facility that are consuming everything on their tray or are not anorexic, but they are still losing weight, you may need to look for other conditions such as:

• Hypermetabolic states(example-hyperthyroidism)
• Acute infections
• Wound healing
• Wandering
• Anxiety and paranoia
• Repetitive movements
• Malaborption
  
  

The importance of a speech therapy evaluation for residents with unintended weight loss was pointed out. In addition to recognizing when a resident is experiencing dental and oral pain, esophageal reflux disease, difficulty swallowing(dysphagia),completely unable to swallow (aphagia) are other factors that contribute to unintended weight loss that may be diagnosed by a speech therapist.

If weight loss is not unavoidable there are some measures that can be taken such as:

• Change/enhance the diet
• Utilize adaptive devices to get food to the mouth
• Reassess the drug regiment for side effects
• Provided treatment and or palliation of medical conditions
  
  

The issue of aspiration was discussed as a nutritional concern by Dr. George Taler during this broadcast. He identified some "myths" relate to aspiration in long term care residents such as:

• Clinically asymptomatic aspiration may not be associated with an increased risk of aspiration pneumonia
• The thought that tube feedings reduces the chance of aspiration
  
  

Dr. George Taler identified ways in which aspiration can be prevented in your long term residents by utilizing methods such as:

• Sitting the resident up at time of feeding
• Prompting the resident to eat
• Providing the resident with warm social relationships at feeding time
• Providing finger foods
• Honoring food preferences
  
  

Dr. George Taler pointed out that "thicken fluids" are difficult to swallow and pureed foods can be problematic, because they lose their taste.

Dr. George Taler also identified the use of feeding tubes as a nutritional concern in long term care. Indications for the use of feeding tubes included:

• Dysphagia/aphagia
• Choking due to strokes
• Surgery(e.g.. radical neck)
• Gastrointestinal obstruction
• Patient or family preference
  
  

In concluding this broadcast the physician, Dr. George Taler provided the audience with some "final thoughts" related to nutritional and hydration in long term residents. These are:

• Evaluate the nutrition and hydration status of your residents at admission and intervene early.
• Tools for evaluation should be standardized
• Policy and procedures at the facility should empower the staff to act
• In hypermetabolic conditions, adding more food as oppose to supplements are useful
• Nutritional care alerts are a tool to alert staff to problems
• For anorexic patients the use of supplements between meals and with medication passes is useful
• Providing hydration as medication for residents who have lost their ability to recognize thirst (i.e. dementia residents) is useful.
• Encourage hand-feeding
• Look at the patient and where they are in the course of their illness
• We should provide a balance between expected benefits vs harms in terms of our interventions
• Placement of the feeding tube should not be the final measure of success.
• Reinforce the use of the interdisciplinary team
• The desired result, appropriate, nutritional intervention, and plan of care consistent with the patients wishes are the goal of the evaluation.
  
  

We hope this information is useful, if you have any additional questions and/or comments feel free to give us a call or e-mail.

Sincerely,

Quality Improvement Nurses