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by Steven Levenson, MD, CMD
Chair, Caring's Editorial Board
Multi-Facility Medical Director
Towson, MD
Few aspects of nursing home care are more controversial than nutrition. But that's at least partially because nutrition is a controversial field. As a recent article in US News and World Report (July 22) stated, "the medical establishment serves up a generous portion of studies about food every year. Many of them are so conflicting they're impossible to digest."
As with much nursing home care, current practices related to nutrition and hydration are similarly perplexing. They reflect a mix of technically proficient and medically valid interventions combined with lots of habit and personal opinions. The result? Some approaches help patients and should be used universally, while others are questionable and should be discarded, or at least not promoted as standards.
Since 1996, AMDA's Clinical Practice Guideline (CPG) project has focused on modernizing and standardizing long-term care policies and practices. Its purpose is to combine evidence about various care topics with recognition of proper care process. The resulting CPG is then usable for reviewing and adjusting current processes and practices in nursing homes.
AMDA's CPG on Altered Nutritional Status, released at the 25th Anniversary Symposium in March, is revolutionary in the sense that it provides long-term care practitioners with detailed, widely applicable, and workable approaches to an area of care that is now subject to great variability. At the same time, the CPG recognizes that nutrition management must be individualized, not just follow a "cook-book" approach.
This special report will cover highlights of the new CPG and explain how it can potentially transform nursing home practice.
| Key Points about Nutrition in LTC |
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Nutrition provides vital energy and building blocks for all of the body's processes and structures--but it never operates independently of the body. The body's organs and chemical processes must function adequately and be able to use nutrients effectively. If they cannot--because of age, disease, or another problem--then all the nutrition in the world may be to little avail. All nutrition issues must be considered and managed in the context of each person's overall function and underlying conditions and prognosis.
What, for example, is the clinical significance of weight change? In short, that depends. Weight is a screen, not something to be treated as an end in itself.
Furthermore, OBRA indicators regarding weight changes are not definitive. They provide nursing homes with a framework for paying closer attention to the situation--but, weight loss is not necessarily the most significant indicator of an urgent problem. In many patients, anorexia--the loss of appetite or marked reduction in food intake even before significant weight loss occurs--is a more urgent concern.
There is no clear benchmark for the degree of weight change that should prompt a thorough evaluation. However, rapid weight change may have negative clinical implications. In fact, the rate may be more important than the degree.
Nor is there widespread agreement on the appropriate diagnostic and therapeutic approach to weight change. There is, however, evidence that a good, basic patient evaluation is as reliable an indicator of nutritional status as any lab test.
In fact, lab tests such as albumin may actually be misleading or may measure other aspects of a patient's status--for example, the effects of illnesses such as nephrotic syndrome or liver cirrhosis (J Am Geriatr Soc 2002; 50:631-637).
Thus, significant unintended weight loss could indicate undernutrition or it may be a significant clinical indicator of worsening health status. Undernutrition is associated with a higher risk of certain physical problems. However, the converse is not necessarily true--that is, nutritional interventions do not necessarily fix abnormal lab test results or prevent continued physical or functional decline.
When should weight loss be addressed vigorously? When there is some point in doing so--for example, when a realistic overall patient goal is for stabilization or improvement, and when adjusting nutrients has some plausible potential to affect a patient's physical function, well being, and quality of life.
What are the essential steps involved in nutrition and weight management? Simply put, they are the same as for any other symptom, condition, or situation. The generic care delivery process--recognition, cause identification/diagnosis, management, and monitoring--applies. Effective implementation of a sound nutrition-management program requires long-term, facility-wide commitment to review and improve care processes.
No one discipline can manage all of these aspects of the care process. But a correct process must occur sequentially, regardless of who is responsible for doing those steps. For example, it is generally advisable to establish nutritional goals only after the "big picture" for the individual patient is understood.
Correcting hydration imbalances may show results within hours to days (for more on hydration issues, see "How to Handle Hydration & Fluid Maintenance" below). But nutritional deficits or imbalances may not be corrected for weeks or months, if ever. In addition, the body can only handle so much nutrition at a time. No matter how undernourished a nursing home resident may be, correcting nutritional deficits--including selection and administration of supplements--is largely by trial and error. The real issue is whether staff are trying to monitor overall patient progress, including weight, and are making reasonable attempts to adjust interventions.
During the recognition phase, the focus is on collecting evidence to identify actual or potential problems. In fact, as the AMDA CPG notes, most pertinent factors such as weight and eating patterns and limitations can be readily identified. More information is not necessarily better. Nursing home staff don't need to conduct elaborate evaluations or fill out many forms with similar information.
The staff and a health care practitioner should look at the patient and estimate nutritional status by assessing the whole picture--that is, the patient's condition, prognosis, and so on. Ironically, the simple direct observation of the patient has been underestimated as a useful approach to judging nutritional status and its worth has been overestimated in relation to hydration. Direct observation can help reliably identify malnourished individuals, although no signs or symptoms are consistently reliable indicators of fluid balance.
Staff and practitioners should seek nutritional risk factors and evidence of anorexia or weight loss that may signal underlying medical (e.g., medication side effects, delirium, or thyroid dysfunction) rather than nutritional problems. Staff should obtain an admission weight and height and a dietitian should calculate a body mass index (BMI). Although it may be difficult to obtain height in some patients, there are alternate means for estimating it, such as arm span, knee height, or recumbent height.
Although the BMI has limitations, alternative scales have not been shown to be better and may be more arbitrary. BMI may help estimate nutritional risks or deficits. However, estimating appropriate calorie and nutrient needs for individuals is an art with some scientific basis. Regardless of the tool selected to assess nutritional status, it should be used and documented consistently to permit valid comparisons over time.
Some of the information relative to nutritional issues--e.g., observing eating patterns and documenting food intake--is straightforward. But some important information--e.g., complications during a recent hospitalization or current medications that may predispose to anorexia--is indirect. Therefore, assessment and recognition are shared responsibilities among many disciplines, and cannot be simply deferred to dietitians or other consultants. Nurses and physicians must review and recognize important information such as that contained in the hospital discharge summary to find clues to nutritional status and risks.
Weight stability (in the absence of significant fluid excess or loss) is a useful indicator of overall nutritional status. Weight reflects a balance between calories ingested and burned. Many conditions (diarrhea, renal failure, heart failure, etc.) may influence nutritional balance simultaneously; it is impossible to calculate specifically the exact contribution of each one to overall nutritional status.
Stable or improving weight generally reflects a positive caloric balance. If weight is declining, then the patient may need more calories or the conditions that create a hypermetabolic state may need to be corrected. If neither is possible, then the causes of decreased intake or increased calorie utilization should be sought.
Other than weight, no marker of nutritional status has proven reliable (sensitive and specific) enough that it should be done routinely in a long-term care population. And, no lab result alone can show that a nutritional intervention is needed.
Nutrition is inseparable from other aspects of health and function. Therefore, nutritional goals must be developed in the proper context and should not be set by a single individual or discipline. Often, it is not realistic to anticipate improvement in lab test results or other nutritional parameters, especially for individuals who are seriously ill or have catabolic conditions such as skin breakdown or renal failure.
Modest nutritional goals such as weight stabilization or moderate weight gain over weeks or months may be realistic. Goals such as "will attain ideal body weight" or "will gain 10 pounds in next 90 days" may be wishful thinking.
It isn't always possible to determine relevant goals when first evaluating an individual or initiating interventions. Therefore, initial conclusions and interventions should be tentative until a more complete evaluation is done and relevant goals are identified.
In some instances, nutritional goals conflict with other goals. For example, someone may be losing weight while on a restricted diet or cholesterol-lowering drugs, or may be undernourished but at risk of aspiration. In such cases, geriatric principles should apply; potential goals and approaches should be analyzed and reconciled by looking at the big picture.
Goals may need to be prioritized and risks may need to be tolerated because of potential benefits of an intervention. The final decision should be made in conjunction with the patient, family, and a health care practitioner who can put the options in perspective.
When there is concern about whether an individual is eating enough, it helps to measure food intake. But there is no foolproof method for doing so. After considering the options, a simple approximation of the percentage of each food group (meats, vegetables, etc.) consumed at mealtime is as good as any other method.
Some lab tests may occasionally help in managing nutritional issues in select patients. But the utility of a test depends on what was already done and on the point of doing it. "Chasing" test results--that is, trying to adjust interventions based on serial lab test ordering--is rarely beneficial and often irrelevant.
Serum albumin and cholesterol testing may be helpful in establishing prognosis, but not for serial monitoring of nutritional status. Some recent evidence suggests that serum albumin measures certain aspects of a person's status but does not correlate well with clinical observation of nutritional status (J Am Geriatr Soc 2002;50:631-637).
Pre-albumin testing should be limited primarily to the initiation of enteral or parenteral nutritional interventions in critically ill patients. Generally, it doesn't help improve the management of most patients and it's expensive.
If someone with a low albumin receives approximately 1.2 to 1.5 gm protein per kg of body weight daily, then the albumin will either increase or it won't. If it does, then the individual should continue to receive the recommended protein allocation; if it doesn't, there is no good evidence to suggest that giving more protein will make the albumin rise higher or faster.
Follow this link to Part 2 of the article.
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This article originally appeared in Caring for the Ages, September 2002; Vol. 3, No. 9, p. 10-14. Caring for the Ages is an official publication of the American Medical Directors Association, published by Elsevier. This article may not be reproduced in any form, print or electronic, without permission. The opinions expressed
by the authors are their own |
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