Innovative Ways to Ensure Optimal Nutrition & Hydration in LTC (continued)

Follow this link to Part 1 of the article.

Meal Time is Social Time

Innovative nutrition strategies recognize not only the necessity of food and drink to sustain well-being but also the importance of eating as a social event, the experts agreed. Such strategies also recognize that all staff at a long-term care facility take active roles in maintaining residents' nutrition and hydration.

These concepts are embodied in Mount Carmel's meal programs. At lunch and dinner, residents come to the dining room and are seated at preset tables. The nursing staff then goes to steam tables, where dietary staff dish out food that the residents selected the previous day. A dessert cart displays the final course. Currently, alternate selections are available in case the resident decides against the preselected food, said Mr. Daehn, who plans to switch soon to a full-selection menu. "Residents don't always remember what they selected, and this will give them more choice."

Mr. Daehn takes a different approach to breakfast. "Variety is hard with the standard breakfast menu," he said. "Breakfast also is the best meal of the day in terms of consumption for many residents." In Mount Carmel's breakfast cart program, which won Healthcare Food Services magazine's Emerald Award for Best Food Service Operator, nursing and dietary staff go together to residents' rooms with a breakfast cart. If a resident does not want the food selected the previous day, the cart is right outside the door so that other fare can be substituted. About five nursing assistants begin the breakfast cart rounds, and they move out as needed to assist residents with the meal.

"This program is especially good for cognitively impaired residents. If someone is having a bad day, pacing about and not connecting, the staff might just give her a banana or some other finger food that she can eat as she walks," Mr. Daehn noted. He added that residents who prefer to socialize at breakfast can take their meal in a common room with other patients, rather than in their own room.

At the 64-bed Iosco Medical Care Facility, all residents eat at the same time, joining people whose company they enjoy. Dishes are taken off trays and put on the table to eliminate the institutional feel. In a separate dining room, eight to 10 residents with midstage dementia eat family-style with aides. "This helps patients who get distressed in a bigger dining room, need extra help, benefit from a quiet atmosphere, or might become disruptive. It's better too for more cognitively intact residents who don't want their meals spoiled by other people's disruptive behavior," said Ms. Henderson.

Although some residents require the assistance of trained personnel to assure that they are eating and drinking enough, others just need a little friendly encouragement. "Healthier residents can provide verbal or visual cues to a friend to eat more," said Dr. Shewmake. Volunteers and members of the community also can assist in this fashion, he added. Many family events outside an institutional setting center on eating, and family ties at meals can carry over into a long-term care facility. Dr. Shewmake noted that residents eat more when family members bring in their favorite foods.

On the Lookout for Problems

The facility-wide and individualized approaches described above to assure good nutrition will be effective in most cases. But occasionally, despite everyone's best efforts, a resident will start to lose weight. "Weight loss may be a sign of inadequate nutrition. It also is a marker of a possible poor outcome," said Dr. Taler.

Frequent weighing of patients will help detect weight loss before a serious problem develops. The standard criteria that trigger assessment are weight loss of 5% in one month, 7.5% in three months, or 10% in six months. "If a patient has been losing weight three months in a row, even if it's not as much as 7.5%, you should do an evaluation. It's better to catch a problem earlier than later," said Dr. Taler.

Another early warning sign is failure to eat or drink as much as usual. Staff should be alert to the possibility of a problem when a resident leaves 25% or more of served food uneaten. "The more acute the appetite loss, the more acute is the problem," said Dr. Taler, citing an acute illness as the most common reason for sudden anorexia. Continued failure to consume an entire meal, however, could be a warning of an impending nutrition or hydration problem.

Staff at nursing facilities need to be keenly sensitive to symptoms of dehydration, which may be subtle. "Dehydration should be part of the differential diagnosis in a patient who appears confused," said Dr. Musher.

Dr. Weinberg added that "we need to teach CNAs to detect changes in fluid intake and functional state quickly and to report them immediately to the nursing supervisor. We want to detect a problem before obvious dehydration develops."

If a patient's food or fluid intake is not optimal, the reasons need to be determined. AMDA's new guidelines emphasize looking for the root cause of the problem. "The guidelines move away from a diagnostic point of view to the overall clinical picture. The goal is to treat the whole person instead of an ailment or a single condition," said Dr. Taler. This goal is achieved by a comprehensive search for treatable causes.

The Altered Nutritional Status guidelines take a two-tiered approach to assessment and treatment of a patient who is losing weight. The first tier is a multidisciplinary approach examining common causes of weight loss. "The Tier-1 assessment looks for reversible causes of weight loss. If the patient continues to lose weight after these problems have been addressed, then, provided the patient and family are willing, the physician undertakes a Tier-2 assessment, looking for unusual causes. If none can be found, weight loss apparently is due to irreversible causes," Dr. Taler said.

The Tier-1 assessment is multidisciplinary because common causes of weight loss include such diverse factors as depression, dental problems, medication interactions, difficulty with self-feeding, and numerous other conditions. Because several factors may contribute simultaneously to weight loss, the evaluation does not end when a single potential cause is identified; all possible factors are explored, and all contributing causes should be documented, along with plans to correct them and results of the treatment.

Dr. Taler noted that the guidelines are purposely vague about who should coordinate this multidisciplinary process. "Each institution has to decide who is responsible for seeing that the Tier-1 evaluation is done and that closure is achieved. It could be the dietitian, the charge nurse on the patient's floor, or somebody else," Dr. Taler said.

Reversing Nutrition & Hydration Problems

Corrective action is usually self evident once the root cause is identified. Remedial steps may include a change in medication, modification of the eating environment, increased assistance with meals, or changes in the food served to reflect ethnic preferences or to accommodate functional disability such as difficulty chewing or swallowing. The possibilities are as varied as the problems identified, and the solutions must be individualized. The patient's preferences tailor the treatment plan.

If the patient has become dehydrated, the fluid-electrolyte imbalance should be corrected as quickly as is safely possible. The general guideline in AMDA's new document is to replace half of a fluid deficit within 24 hours and the remaining deficit over the next two or three days. The oral route is preferred, unless the patient is severely dehydrated. Hypodermoclysis, or subcutaneous fluid administration, carries less risks and requires less training than intravenous administration and may be an option if the patient cannot safely take enough fluids orally.

Two controversial treatments for poor eating merit mention: appetite stimulants and tube feeding. Dr. Taler observed that few studies have been done on use of appetite stimulants in nursing facilities. In general, only about half the patients who take these medications gain weight, and it takes a few months before results are seen. In patients for whom appetite stimulants are effective, weight gain stabilizes after a few months. At that point, the medication can be discontinued, Dr. Taler said.

Tube feeding, the experts agreed, should not be the first response to weight loss. "Tube feeding is a drastic step for a patient who stops eating, and it may not improve the situation. It may be better to feed anything that the patient will eat to maintain caloric input, and to increase the caloric density of foods," said Dr. Shewmake. Dr. Taler added that a tube-fed patient who continues to lose weight is either not being given enough calories or is in a terminal state.

Patients at the End of Life

Weight loss and impaired water balance due to irreversible causes are common at the end of life. "In end stage, the body is closing down and does not process food or fluid," said Dr. Musher.

AMDA's new guidelines recognize this physiologic fact. "We should not subject a patient unnecessarily to assessment if neither therapy nor outcome will be affected," Dr. Taler said, explaining the guideline's recognition that exhaustive assessment and treatment may not be appropriate. But, he added, "the bottom line is that we have to accept the patient's desire for evaluation and treatment."

It may be difficult for health care providers, family members, and regulators to accept that nothing will be done when a terminal patient is not eating or drinking. "Most people don't realize that dehydration is part of the normal dying process and that many dying people do not want to eat and cannot use the food they do ingest," said Dr. Musher. "It's important to understand that going without food and fluid is not painful at the end of life."

The AMDA guidelines emphasize documentation of treatment decisions, including the decision not to force fluids or not to tube feed. The factors taken into consideration in making the decision need to be explained in writing.

A decision to withhold unwanted food and fluids does not mean that the patient is being abandoned, however. "Staff can offer oral supplements, which the patient may or may not accept," Ms. Sherman suggested. "Oral supplements provide fluids and help maintain a minimal energy level. In some cases, the patient may not be eating because he is too tired to eat."

In Mr. Daehn's facility, end-of-life residents are asked each day what they would like to eat. "If the resident says, 'I don't want lunch. I'll just have a few crackers,' that's what we give," said Mr. Daehn. "If the patient says he would like to have an avocado, he'll get an avocado, even if we have to go out to buy one."

Medical journalist Laurie Lewis is a Contributing Writer to Caring.

back to top