AMDA: Publications - Caring for the Ages

The Minimum Data Set (MDS) is a required collection of information and the Resident Assessment Protocols (RAPs) are a general guide to interpreting that information. But no regulation or related document alone enables good geriatrics practice. Important information related to nutritional status such as recent acute illnesses or medications associated with anorexia may not be present in the MDS. And the RAPs never substitute for a careful patient-specific assessment of whether symptoms represent problems that need interventions, or which interventions a specific patient needs.

Cause Identification

Cause identification may be pursued in phases. The AMDA CPG recommends a Tier I Assessment first, to identify causes of a nutritional problem that are common, easily identified, and reversible in some cases.

The Tier I assessment should establish whether an individual is eating what they are already given. Current medications should be reviewed for possible adverse drug reactions. Medications, alone or in combinations, may cause weight loss by causing anorexia, dysphagia, lethargy, confusion, or other problems that affect eating. It is easy to check standard drug references such as the Physician's Desk Reference or online (www.ltcnutrition.org) to identify medications associated with these symptoms.

Also, it is helpful to look for any functional impairments that may affect eating and for oral, dental, or chewing problems that may interfere with eating. Often, such simple, inexpensive actions as helping someone to eat bring significant improvement.

In addition, non-essential dietary restrictions should be loosened or removed, since very few individuals benefit from special diets or disease-specific supplements such as those promoted for respiratory diagnoses, diabetes, or mild-to-moderate chronic renal failure; tight calorie restrictions for diabetes; low-fat diets for hyperlipidemia; or rigid, salt-restricted diets for hypertension or mild congestive heart failure. This is especially important when there is continuing weight loss in the face of altered consistency or other restricted diets.

A Tier II Assessment should be reserved for identifying uncommon conditions or diagnoses for which cure is less likely. These conditions may not be treatable, but identifying them may affect prognosis, alter goals of care, and redirect the care plan. Such an assessment may not be appropriate in all cases.

Unremitting weight loss despite identifying causes and instituting realistic interventions may be considered evidence of end-stage or terminal disease. A gastric feeding tube might be helpful if there is a realistic chance for functional recovery and medical stability. But in most chronically ill elderly, tube feeding does not improve outcomes and may be associated with complications. There is a clear trend towards viewing tube feedings as neither an ethical nor medical obligation.

Swallowing Issues

Appropriate management of an individual with a swallowing disorder or aspiration risk is controversial and often unclear. Management of this situation has become permeated by fear and, as a result, habit and opinion may overwhelm evidence and the care process.

Swallowing and chewing abnormalities are symptoms, not diseases. Like any other symptoms, they do not necessarily demand treatment. In most cases, an appropriate nursing and physician assessment is sufficient to identify individuals with swallowing abnormalities and to try pertinent interventions such as modified food consistency and smaller portions.

Management of all geriatric conditions involves some risks. No known evaluations or interventions can guarantee that someone will not aspirate. It is important to note that many elderly individuals with swallowing abnormalities and aspiration risk do not get aspiration pneumonia. In fact, there is evidence that altered consistency diets may increase the risk of nutrition and hydration deficits. Thickened liquids and pureed foods are often poorly tolerated. Tube feedings do not materially decrease the risk of aspiration.

Speech therapy may be useful in select situations--for example, for individuals with new strokes. But there is no regulatory or clinical requirement for immediate intervention or the routine use of a speech therapist or other consultant. Before formal swallowing studies are authorized or performed, nurses and a health care practitioner should seek other possible conditions that may affect eating, chewing, or swallowing. Medications may directly and indirectly affect chewing and swallowing, for example, as may oral, dental, and pulmonary problems that cause coughing or choking.

Multidisciplinary team members, including health care practitioners, should be involved in balancing the risks of aspiration against the potential benefits of more liberal diets and food consistency, and deciding whether there are viable alternatives. There should be a discussion of the patient's prognosis, goals, and objectives. Often, aspiration risks must be tolerated because of other, more immediate or probable risks such as nutrition or hydration deficits.

It is appropriate to warn individuals about risks associated with choosing any treatment option. Some individuals clearly are unable to swallow effectively, and should have food consistency modified. But excessive pressure to limit dietary intake because of "silent aspiration risk" may be largely unwarranted. Some families should be warned about unrealistic expectations--e.g., demands to feed individuals with markedly impaired swallowing. But patients or families should not be required routinely to sign releases before individuals with modest aspiration risk can eat.

Nutrition & Skin Problems

Myths and habits have evolved related to individuals with wounds. Staff at many facilities institute automatic supplementation with calories, protein, vitamin C, and zinc for any wound. When wounds don't heal as anticipated, they add even more nutritional supplementation.

However, there are no wound-specific nutritional measures. Nutritional needs for individuals with wounds are the same as for any catabolic situation: provide enough for metabolic processes and structural repair.

Modest goals for individuals with wounds and compromised nutrition should include weight stabilization and striving for total daily protein intake of approximately 1.2 to 1.5 gm/kg body weight daily (possibly more for large, extensive, or multiple wounds). A single daily multivitamin with minerals is sufficient; there is no proof that more elaborate vitamin and mineral supplementation is better.

If wounds don't heal as anticipated, other critical factors affecting wound healing should be addressed, such as infection of the soft tissues around the wound, removal of dead tissue from the wound, and proper care of the resident overall.

Skin tears do not require additional nutritional interventions and vascular ulcers or stasis ulcers are unlikely to benefit from routine nutritional interventions unless the person has compromised nutritional status.

Anorexia & Depression

Another controversial trend in long-term care has been to promote the use of antidepressants, megesterol acetate, oxandrolone, and other medications as "appetite stimulants." But good practice supports carefully considering various causes of anorexia and looking at all the factors associated with poor intake before adding drugs to the regimen of individuals who are often already overmedicated. Many medications, alone or in combination, can cause anorexia directly or indirectly by contributing to lethargy, weakness, or confusion, affecting taste or salivation, or causing nausea.

It is important to note that antidepressants are not uniformly effective in increasing appetite. For instance, evidence provided by the manufacturer of one antidepressant commonly used as an appetite stimulant shows that it increased appetite in only 17% of patients and only 12% gained weight, whereas the medication had a considerable risk of undesired side effects such as somnolence (experienced by 54%).

If depression is suspected, it should be confirmed by a bedside clinical evaluation and objective review, such as use of a depression scale.

Before starting patients on these medications, staff should carefully assess, document, and report the details of symptoms (anorexia, weight loss, etc.), so that health care practitioners can help them identify causes and consider relevant interventions.

Nutrition Interventions in Context

As the AMDA CPG indicates, before instituting a nutritional care plan, it helps to summarize the patient-specific evidence, including:

A general problem statement of the whole situation (that is, nutritional issues and goals in the context of the individual's overall conditions and prognosis) is also useful.

The goal of nutritional interventions should be realistic and individualized. For individuals who have recently lost weight or who are underweight, the initial endpoint should be weight stabilization. Weight increase may take time, especially after a recent severe or prolonged acute illness. Facility staff should try to stabilize and improve nutritional status, where possible, but failure to regain weight should not necessarily be considered the result of faulty care.

As with the management of any condition, nutrition interventions may be symptomatic (e.g., giving more calories) or cause-specific (e.g., addressing causes of anorexia). A health care practitioner should analyze specific findings and discuss with staff whether swallowing abnormalities or other symptoms (e.g., coughing while eating) constitute a problem, and how the symptoms relate to the problem of anorexia or weight loss. Are they causative or coincidental? Is something else important occurring simultaneously? Why does the condition warrant treatment? What are the relative risks and benefits?

Proposed interventions should be relevant to the big picture. Definitive treatment recommendations should await a systematic review of goals, objectives, and overall condition and prognosis.

The Bottom Line

In the frail elderly and chronically ill, many circumstances influence the nature and types of appropriate nutritional interventions. We should approach the issue as another example of how various individuals must play appropriate parts in the care-delivery process. As with all aspects of nursing home care, it's time to get back to basics and simplify processes that are unnecessarily confusing and complicated.

Dr. Levenson is a Multi-Facility Medical Director in Baltimore and Chair of Caring's Editorial Board.

How To Handle Hydration & Fluid Maintenance

Hydration and dehydration are common--but often misunderstood--concerns for all frail elderly. The AMDA Dehydration and Fluid Maintenance CPG helps address misconceptions and clarify related responsibilities.

The body's fluids consist of water and dissolved substances, including sodium, potassium, and other electrolytes. These are essential to life and require proper balance. Therefore, appropriate management and monitoring require more than just giving fluids and watching intake and output.

Nursing home staff should be able to identify risk factors--vomiting, diarrhea, fever, use of diuretics or ACE inhibitors--for developing fluid and electrolyte imbalance, and know that the signs and symptoms of fluid and electrolyte imbalance are nonspecific; they may resemble those caused by other conditions such as adverse drug reactions and acute infections.

Fluid and electrolyte balance cannot be assessed by looking at the individual, because no physical signs or symptoms are reliable enough indicators of impaired hydration. Therefore, fluid and electrolyte imbalance should be considered when nonspecific condition changes--including lethargy, falls, anorexia, etc.--are not readily explained by other conditions or do not respond readily to interventions aimed at other presumed diagnoses.

Effective monitoring for hydration problems include a review of current or subsequent changes in:

Food or fluid intake
Level of consciousness
Mental status
Urine output
Body weight (particularly rapid or abrupt changes)

A physician should then evaluate the patient's situation by, for example, ordering BUN, creatinine, electrolytes, or other relevant tests that assess the patient's fluid balance.

Some fluid and electrolyte imbalances can become medical emergencies. It is important to identify an imbalance as mild, moderate, or severe based on criteria such as those in the AMDA CPG. To enable proper treatment, relative deficits or excesses of sodium and water should also be defined.

Since fluid and electrolyte imbalance often has identifiable causes, causes of fluid and electrolyte imbalance should be categorized along the following lines:

Inadequate intake (e.g., dysphagia, dementia, delirium)
Excessive loss (e.g., diarrhea, fever, diuretics)
Impairment of the body's ability to balance and manage fluids and electrolytes (e.g., renal failure, heart failure, cerebrovascular accident, syndrome of inappropriate antidiuretic hormone secretion, diuretics, ACE inhibitors, and other medications)
Combinations of the above

Appropriate management is based on consideration of the nature, severity, and causes of fluid and electrolyte imbalance and the impact of fluid and electrolyte imbalance on an individual's functioning and quality of life.

Where appropriate, factors that directly or indirectly caused or contributed to fluid and electrolyte imbalance should also be managed--for example, treating pneumonia or heart failure that caused lethargy and confusion, resulting in decreased fluid intake; reducing diuretics that may have caused excessive diuresis; reducing ACE inhibitors that may have worsened sodium imbalance.

Individuals who have had previous episodes of fluid and electrolyte imbalance and have conditions that place them at risk for fluid and electrolyte imbalance should be monitored, as indicated above.

The timely identification and management of earlier, more subtle stages of fluid and electrolyte imbalance can often prevent progression to full-blown dehydration.

Changing Perspectives on LTC Nutrition & Hydration (continued)

Regulations & Nutrition