Innovative Ways to Ensure Optimal Nutrition & Hydration in LTC

by Laurie Lewis

The latest word in nutrition for long-term care facilities is choice. Ask residents what they want to eat. If they don't eat what's offered, find out why, and don't stop with an easy answer. But should a patient in end-stage disease not want to eat, don't force the issue.

Does this sound like an expensive, time-consuming, suboptimal approach to nutrition? Rich Daehn, CDM, FSD, Director of Dietary Services at Mount Carmel and Director of Benedictine Health System Nutritional Centers of Excellence, both in Milwaukee, WI, will tell you otherwise. Since Mr. Daehn instituted restaurant-style lunches and dinners and started delivering breakfasts to the residents' rooms, the cost of dietary services has decreased about $1.60 per patient per day at Mount Carmel. The facility did not have to increase the number of dietary workers or nursing aides to implement the program. Furthermore, staff feel more connected to the residents.

"Before, dietary staff rarely saw the residents. Now they are real people," Mr. Daehn said. "This is a quality-of-life-driven program. It increases quality of life for both residents and staff."

The individualized approach to nutrition is emphasized in two sets of Clinical Practice Guidelines that the American Medical Directors Association is issuing this month (see box in Part 2 of this article). Both the Altered Nutritional Status guidelines and the Dehydration and Fluid Maintenance guidelines point to the need to assess residents at risk, identify the root cause of any problem, and, provided the patient is willing, implement a plan to improve the situation. The entire process, from assessment through intervention and monitoring, is interdisciplinary.

Because nutritional problems and dehydration often are rooted in the same cause, patients may be affected by both weight loss and fluid imbalance. "Patients who are malnourished are usually dehydrated," said Jonathan Musher, MD, CMD, Corporate Medical Director of Beverly Health Care in Chevy Chase, MD. "Dehydration actually may be more common in elderly people because it can happen quickly" (see box below for the definition of dehydration).

Initial Assessment Highlights Patient Preferences

For a facility that is both home and health care provider, nutrition is a concern from day one. "Many patients, even those who had been living independently immediately before admission, have some degree of malnutrition when they enter a long-term care facility," said Roger A. Shewmake, PhD, Professor and Director of the Section of Nutrition at the University of South Dakota School of Medicine in Sioux Falls. He attributed poor nutritional status among community-dwelling elderly to a variety of factors, including bad eating habits, insufficient money to buy enough food, and inability or lack of desire to prepare healthy meals.

Because of the high potential for nutritional deficits, nutritional assessment is essential upon admission, and a baseline evaluation of the patient's nutritional status is the initial step in AMDA's new nutrition guidelines. The assessment includes measurement of weight, calculation of body mass index (a ratio of weight to height), and determination of the patient's eating preferences.

The latter assessment is where attention first turns to individual choices. What does the resident like to eat? When does she usually eat? How much does she eat at one time?

Individual preferences in areas other than food, such as sleep-awake patterns, may also affect residents' nutritional status. Someone who is in the habit of sleeping late and staying up until the wee hours may not eat well on an institutional meal schedule. "We are accustomed to setting patients to our clocks. That's not necessarily what's best for the patient," noted Jane Henderson, RN, Director of Nursing at Iosco Medical Care Facility in Tawas City, MI.

Some Common Risk Factors for Nutritional Problems and Dehydration
Risk Factor	Nutritional Problem	Dehydration
Recent weight loss
Dementia, cognitive impairment
Inability to feed self without assistance
Difficulty swallowing
Depression
Certain medications
Restricted diet
End-stage disease
Pressure ulcer
Infection (acute or chronic)
Fever
Diarrhea or vomiting
Repetitive movement, restlessness
Excessive sweating or urination
Previous episodes of dehydration

At the initial assessment, risk factors for nutritional problems and dehydration should be identified. These risk factors are so common in elderly people that most residents of long-term care facilities will have at least one or two (see box at right), according to our experts. The risk factors cover situations that touch many professional disciplines, including medicine, nursing, dietary, pharmacy, and occupational therapy.

Besides interviewing the resident or family to determine risk factors, staff can learn a lot through observation, said Jamie Sherman, RD, Clinical Dietitian at Genesis ElderCare in Randallstown, MD. "I look at the patient--the face, the skin, the hair." Sunken cheekbones, wrinkled skin (which Ms. Sherman described as different from normal elderly skin), and dull, colorless hair may indicate nutritional problems or fluid imbalance, she noted. In addition to looking at the patients, staff also should observe the types and quantity of food the new resident eats, and the degree of difficulty he or she experiences while eating.

Good for All & Special for Some

While keeping individual preferences in mind, a long-term care facility must also address the nutritional needs of all residents. The two biggest decisions are when to serve food and drink and what to offer.

"A resident may not eat well if the facility's meal pattern differs from what he or she is accustomed to," said Dr. Shewmake. He urged facilities to offer something to eat every three hours. That way, residents who don't want to eat a big breakfast, lunch, or dinner will meet their nutritional needs with snacks as well as meals.

Nightowls often have little interest in breakfast, said Ms. Henderson. "Some of our residents who are awake at night eat more on the night shift than they do during the day." Nightowls who need extra help with meals might eat best during the late shift, she added, because staff can give them more attention then.

Dr. Shewmake mentioned the importance of having a location where residents know they can find food. Good items to stock include whole-grain crackers, cereals (especially those that can be eaten as finger foods), fruits, and vegetables. In addition to making these foods available at all times, facilities should bring out snack trays several times a day. Nutrient-dense foods make the best snacks, said Dr. Shewmake. His suggestions include finger sandwiches, smoothies made with fruit and milk, pizza on English muffins with low-fat mozzarella cheese, and celery stuffed with peanut butter.

Snacks can be served during activities such as exercise sessions and music programs. "Activities staff and aides are good at reporting if Mr. Jones, who usually eats his snack, doesn't eat it on a particular day," said Ms. Sherman. When someone who normally enjoys a snack passes up food, the reason may be an acute illness or another problem that requires attention.

Besides encouraging frequent snacking, facilities can increase the caloric content of meals by boosting the nutrient density of foods--for example, by adding commercial nutritional supplements to mashed potatoes. Larger helpings of favorite foods also help raise caloric intake. "Getting enough calories so lean body mass is not burnt up is what counts for elderly patients," said Dr. Shewmake.

Fluids need to be made available and specifically offered to residents throughout the day. "Someone who is not eating and not drinking will die of dehydration before dying of starvation," observed Andrew Weinberg, MD, Associate Professor of Medicine at Emory University in Atlanta, GA, and a member of AMDA's Dehydration and Fluid Maintenance guidelines committee.

Mount Carmel has a hydration pass twice a day. "This is not part of the medication pass or a nutrition pass. For the hydration pass, we offer only punch, juice, and water," explained Mr. Daehn. Popsicles and gelatin desserts are tasty sources of fluid that break the monotony of the usual beverage selections. Dr. Weinberg noted the importance of limiting caffeine-containing beverages, which can cause acute diuresis, even while offering drinks that the resident enjoys.

AMDA's new guidelines call for individualized diets, which are not to be confused with restrictive diets, such as a salt-free or diabetic diet. "Restrictive therapeutic diets usually are not appropriate for 'survivors' who have lived a long time. If denied favorite or tasty foods, a resident might not eat enough and start to lose weight," said Dr. Shewmake.

George Taler, MD, CMD, Director of Long-Term Care at Washington [DC] Hospital and Chair of AMDA's Altered Nutritional Status guidelines group, suggested that elimination of restrictive diets frees the kitchen staff to prepare a wider variety of foods, allows for individualization, and doesn't increase costs. But, he emphasized, "The institution should aim first at meeting patient preferences rather than optimizing efficiency."

"This is our residents' home. You should be able to have what you want in your home, provided it isn't harmful," said Ms. Sherman. She told about one resident who wanted creamed chipped beef for breakfast every morning. She told him that because of his heart condition, he could have it only three times a week. On the other hand, a woman who was underweight on admission and reported her love of ice cream eats the dessert several times a day and has gained 9 pounds in five months.

"Our residents dictate a lot about what they want through the Residents' Council," said Ms. Henderson. Residents have suggested before-meal appetizers such as soup, vegetables, or crackers. Besides stimulating the appetite, the extra treat creates a more social atmosphere in the dining hall.

Follow this link to Part 2 of the article.

Medical journalist Laurie Lewis is a Contributing Writer to Caring.

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