Individualize nutrition care

It’s dinnertime and residents are being seated at impeccably dressed tables. Tonight’s dinner is nutritionally well-balanced, colorful, and inviting. However, when the plates are cleared, it’s obvious that a number of residents have left much of the food behind. Later, it’s discovered that these same residents are unintentionally losing weight. This is a serious red flag for all caregivers because unintended weight loss can be dangerous, especially to a frail adult.

It’s important to have a good nutrition screening program in place to identify nutrition risks such as unintended weight loss. A good nutrition screening program identifies residents at risk of malnutrition, and leads to referral to the registered dietitian (RD) for a comprehensive nutrition assessment. Becky Dorner, RD, LD, president of Becky Dorner & Associates, Inc., speaker-elect of The American Dietetic Association House of Delegates, and a Director of the National Pressure Ulcer Advisory Panel (NPUAP) remarks that “Frail older adults often have difficulty eating enough food to maintain their usual weight. The cause can be multifaceted. Anorexia can be caused by medications, depression, specific conditions, diseases, or other factors. It is essential to determine the underlying cause of the weight loss. For a frail older person, unintended weight loss can lead to additional problems, such as weakness, decline in ability to function independently, malnutrition, and other complications, including pressure ulcers,” she adds.

NUTRITIONAL SCREENING AND ASSESSMENT

Because good nutrition is elemental in maintaining good health, Dorner advises that healthcare professionals monitor how well residents are eating. If disinterest in food or minimal intake is observed, she suggests that simple screenings are performed. “There are a number of validated nutrition screening tools available that can help identify residents who are at risk for malnutrition,” says Dorner. Among them are the Mini Nutrition Assessment®-Short Form (MNA-SF), Short Nutrition Assessment Questionnaire (SNAQ), and Malnutrition Universal Screening Tool (MUST). “These tools,” says Dorner, “provide an opportunity to flag at-risk residents and refer them to the RD for further assessment and intervention.”

ADDRESSING MEDICAL CONDITIONS

If a nutrition assessment indicates an underlying medical problem, nutrition interventions should be implemented immediately. The RD works with the interdisciplinary team to custom-tailor a nutrition and/or dining program for each resident based on his or her individual needs. Individualized interventions may include liberalizing the diet to the least restrictive diet appropriate, altering food texture, providing favorite foods, fortified foods, assistive eating devices, or assisting residents to eat.

If basic interventions don’t resolve the resident’s individual nutrition issues, high-protein, high-calorie oral nutritional supplements can be offered to help maintain or regain weight. These may include a high-calorie and/or protein drink, pudding, or other form of supplementation that the resident will accept. “We should always encourage food first and provide assistance at meal time before we move to offering oral nutritional supplements. However, the important thing is to take an individualized approach which meets each resident’s needs,” Dorner advises.

“Research indicates that adequate calories, protein, fluids, vitamins, and minerals are essential for pressure ulcer prevention and treatment,” says Dorner. “If nutritional deficiency is suspected or confirmed, a daily multivitamin and possibly additional nutrients may be recommended.” According to Dorner, an individual who is either at risk or has a pressure ulcer should receive 30-35 kcalories/kg body weight adjusted as needed for weight loss, gain, or obesity level. Proteins should equal 1.25-1.5 grams protein/kg body weight if compatible with care goals; and renal function should be monitored with increased protein. Fluids should be provided at a level that maintains hydration. This can be estimated at 1 ml fluid per kcalorie consumed or 30 ml per kg body weight.

Thin, undernourished individuals are not the only ones at risk of developing pressure ulcers. Dorner advises that “an obese person can experience unintended weight loss, be undernourished, and at risk for developing pressure ulcers too.” Although the individual might appear to be well-nourished, there may be nutritional deficits and other risk factors for pressure ulcer development, she states.

Another group that can benefit from nutritional interventions is residents who experience difficulty swallowing, or dysphagia. “The RD and speech-language pathologist often work with the interdisciplinary care team to determine the most appropriate diet and liquid consistency for each individual. In addition, the RD and the food service director must creatively address meal preparation and service,” says Dorner. “People need information on how to create nutritious, tasty food for consistency alterations. By following standardized recipes, and presenting food in an eye-appealing form, consistency-altered food

can taste good and people will be willing to eat it,” she states.

Suggested Resources

American Dietetic Association

• www.eatright.org

• For a registered dietitian in your area: www.eatright.org/programs/rdfinder/

National Pressure Ulcer Advisory Panel (NPUAP)

• NPUAP-EPUAP guidelines on pressure ulcer prevention and treatment: https://nationalpres750.corecommerce.com/International-Pressure-Ulcer-Guidelines-for-Prevention-and-Treatment/Books-c1/

• NPUAP white paper on nutrition: www.npuap.org/Nutrition%20White%20Paper%20Website%20Version.pdf

Becky Dorner & Associates, Inc.

• Resources, publications, continuing education program (many free articles, free news e-zine, and information on nutrition for older adults)

• Diet Manual: A Comprehensive Nutrition Care Guide and Dysphagia Diet Solutions are available at www.beckydorner.com

THE CASE FOR DINING DIVERSITY

Dorner notes that as people age, many physiological changes occur that can make food less appealing. It is absolutely essential to provide a pleasant dining experience, and to serve food that looks, smells, and tastes appealing. Residents should be served foods that are familiar to them. Long-term care facilities must meet the needs of residents of varied ethnic, cultural, and religious backgrounds. “Most residents don’t want to sample foods that are strange to them. Instead of being appealing, this may depress appetite rather than stimulate it,” she remarks.

Providing an individualized approach to nutrition care by offering foods that meet the cultural and religious needs of each individual and liberalizing diets to the least restrictive alternative are the best approaches to nutrition care and can also be a positive influence on encouraging appetites.

Long-Term Living 2011 May;60(5):44-45

Sandra Hoban

Sandra Hoban was on I Advance Senior Care / Long-Term Living’s editorial staff for 17 years. She is one of the country’s longest-serving senior care journalists. Before joining Long-Term Living, she was a member of the promotions department at Advanstar Communications. In addition to her editorial experience, Sandi has served past roles in print and broadcast advertising as a traffic and talent coordinator.