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The Journals of Gerontology Series A: Biological Sciences and Medical Sciences 55:M725-M734 (2000)
© 2000 The Gerontological Society of America

Nutritional Management in Long-Term Care

Development of a Clinical Guideline

David R. Thomasa, Wendy Ashmenb, John E. Morleya and William J. Evans, and the Council for Nutritional Strategies in Long-Term Carec

a Division of Geriatric Medicine, Saint Louis University School of Medicine, Missouri
b Programs in Medicine, Newton Square, Pennsylvania
c Donald W. Reynolds Center on Aging, UAMS Medical Center, Little Rock, Arkansas

David R. Thomas, Division of Geriatric Medicine, Saint Louis University School of Medicine, 1402 S. Grand Boulevard, M238, St. Louis, MO 63104 E-mail: thomasdr{at}slu.edu.

Decision Editor: Laurence Z. Rubenstein, MD, MPH


   Abstract
Top
 Abstract
Methods
 The Clinical Guidelines
 Summary
 References
 
Background. Involuntary weight loss resulting from malnutrition is a major problem among residents in long-term care facilities. Although body weight is easily measured, the evaluation of unintended weight loss in long-term care facilities is difficult.

Methods. The Council for Nutritional Clinical Strategies in Long-Term Care, an expert panel of interdisciplinary thought leaders representing academia and the medical community, derived a structured approach aimed at improving management of malnutrition in long-term care settings, using literature review and consensus development. The Clinical Guide to Prevent and Manage Malnutrition in Long-Term Care is based on a best-evidence approach to the management of nutritional problems in long-term care.

Results. The Clinical Guide is divided into two parts, one designed for nursing staff, dietary staff, and dietitians, and a second directed to physicians, pharmacists, and dietitians.

Conclusions. A structured approach to the management of unintended weight loss or malnutrition in long-term care is intended to ensure a comprehensive resident evaluation. While the Clinical Guide is presented in a linear fashion, many of the considerations can be done simultaneously and the order varied dependent on the individual resident's needs. Further research to validate the effectiveness of using the algorithm in long-term care settings will be required.

INVOLUNTARY weight loss resulting from malnutrition is a major problem among residents in long-term care facilities (Table 1 ). The prevalence of protein-energy malnutrition in nursing home residents ranges from 23–85% (1) (2). Among those patients newly admitted to a Baltimore long-term care setting, a point prevalence of 54% malnutrition was observed (3). In a Swedish study, 29% of new admissions to a long-term care geriatric hospital were malnourished, defined by anthropometry, serum protein analysis, and delayed hypersensitivity skin test (4).


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  		Table 1. Nutritional Status of Nursing Home Patients

 
Malnutrition in elderly populations is associated with poor clinical outcomes and is an indicator of risk for increased mortality. Patients with severe malnutrition are at higher risk for a variety of complications (5), and a number of chronic medical conditions are associated with increased risk of malnutrition (Table 2 and Table 3 ). Identification of malnutrition should lead to early intervention, which may correct reversible nutritional deficits.


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  		Table 2. Risk Associated With Undernutrition

 

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  		Table 3. Medical Conditions Associated With Protein Energy Malnutrition in Nursing Home Residents

 
Two Congressional acts, the Omnibus Budget Reconciliation Act of 1987 (OBRA 1987) and the Balanced Budget Act of 1997 have had a major impact on nutrition standards in long-term care settings. The regulations state that, based on a resident's comprehensive assessment, the facility must ensure (a) that a resident maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrates that this is not possible; and (b) that a resident receives a therapeutic diet when there is a nutritional problem.

Body weight is easily measured and used as a critical first sign of malnutrition in the nursing home. Clearly, a large number of nursing home residents lose weight during their stay. Involuntary weight loss, reduced appetite, and cachexia are common in the geriatric population and are often unexplained (6). Appetite is regulated by a variety of psychological, gastrointestinal, metabolic, and nutritional factors. Appetite regulators in the central feeding and peripheral satiation systems have been extensively reviewed (7) (8).

Although body weight is easily measured, the evaluation of unintended weight loss in long-term care facilities is difficult (9). Whether anorexia and weight loss are reversible or unavoidable requires a careful clinical evaluation in the individual patient. A structured approach to the differential diagnosis of malnutrition in long-term care was developed by the Council for Nutritional Clinical Strategies in Long-Term Care.


   Methods
Top
 Abstract
 Methods
The Clinical Guidelines
 Summary
 References
 
An expert panel of interdisciplinary thought leaders representing academia and the medical community joined together to form the Council for Nutritional Clinical Strategies in Long-Term Care. The Council convened a summit meeting in May 1998 to review the current state of the science in nutrition management, to identify major issues surrounding prevention and treatment of malnutrition in the elderly population, and to identify evidence-based recommendations for the management of malnutrition in long-term care. Subsequent to that summit meeting, a comprehensive literature search was conducted through the National Library of Medicine's Medline Database using key MeSH terms, such as anorexia, weight loss, appetite, protein-energy malnutrition, nutritional status, aged and aging.

The Council reviewed existing literature to formulate protocol-driven recommendations to serve as a clinical guide for the management of malnutrition in the long-term care setting. Where evidence existed, it served as the basis for specific recommendations. In the absence of evidence, a modified Delphi approach was used to obtain consensus. The Council conducted a series of regional consensus meetings and a closed Internet discussion forum to gain input from academic thought leaders. This input refined recommendations that were published in March 1999 as a monograph from the Council for Nutritional Clinical Strategies in Long-Term Care, entitled Anorexia in the Elderly (10). The monograph presented the recommendations graphically in a parallel algorithmic approach. The algorithms were formally introduced at a satellite symposium during the annual meeting of the American Medical Directors Association on March 5, 1999.

Subsequent to their publication and introduction, in July 1999, representatives from the American Dietetic Association (ADA) met with the Council to discuss the algorithms in light of the introduction of the ADA's Health Care Financing Administration-mandated risk assessment tool. Pursuant to that meeting, the algorithms were revised to include key quality indicators related to malnutrition and dehydration, minimum data set indicators, and additional food/environmental considerations. In addition, a subcommittee was formed to develop the Nursing Nutritional Checklist for use in care planning aligned with the revised algorithms. This checklist received consensus approval by the Council in October 1999 and was introduced at a satellite symposium during the annual meeting of the American Society of Consultant Pharmacists on November 10, 1999. A series of regional meetings were conducted to present the revised algorithms and nursing checklist and to address questions related to their use within long-term care.

In order to gain support of the algorithms from a respected peer association and establish a research initiative where lack of evidence exists, the Council met with an independent peer-review committee selected by The Gerontological Society of America in February 2000. Based on input from that meeting, the algorithms were retitled Clinical Guide to Prevent and Manage Malnutrition in Long-Term Care. Further revisions were made to provide clarification of specific recommendations and to ensure an understanding that although the recommendations are graphically presented as a linear guide for simplicity, many of the protocol-driven suggestions are intended to be implemented simultaneously with their order varying, dependent on individual resident needs.


   The Clinical Guidelines
Top
 Abstract
 Methods
 The Clinical Guidelines
Summary
 References
 
The Clinical Guide is divided into two parts, one designed for nursing staff, dietary staff, and dietitians and a second designed for physicians, pharmacists, and dietitians. The Clinical Guide for nursing staff, dietary staff, and dietitians ( Fig. 1) and the Nursing Nutritional Checklist ( Fig. 2) are designed to clarify information necessary to develop a care plan and to inform the physician about the resident's condition. The Clinical Guide for physicians, pharmacists, and dietitians focuses on differential diagnosis (see Fig. 3). The phrase "quality indicator conditions" in the figures refers to the Minimim Data Set Resident Assessment Protocol (MDS RAP) triggers.



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  		Figure 1.
 


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  		Figure 2.
 


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  		Figure 3.
 
The Clinical Guide for Nursing, Dietary, and Dietitian Staff
Clinical triggers.-- Both clinical guidelines were originally triggered by three factors. These parameters were derived from OBRA 1987 guidelines: (a) involuntary weight loss of greater than 5% in 30 days or 10% in 180 days; (b) leaving more than 25% of food in the past 7 days or two thirds of meals based on a 2000 kcal diet; or (c) a body mass index (BMI, calculated as weight divided by height squared) of equal to or less than 19.

Age- and gender-adjusted BMI below the 10th dectile has been used to define undernutrition (<19 in men and <19.4 in women). In hospitalized adults with serious illness, excess mortality within 6 months (risk ratio 1.23, p < .001) has been demonstrated when the BMI is less than 20 (11). The increase in mortality is linear—the lower the BMI, the greater the risk. Increased risk of death has been shown to begin at a BMI <23.5 in men and <22.0 in women (12). The Clinical Guidelines revised the BMI at 21, however, because a body mass index of less than 21 has been shown to be associated with increased mortality and may result in earlier intervention (13).

Advanced directives.-- Whenever a resident has a weight loss problem, it is essential that they or their proxy have a full discussion of their health care wishes with a health care professional. A discussion of the treatment goals and the resident's ongoing quality of life should be initiated at this point. The decision that they make should be documented and guide how aggressively the algorithm is utilized.

Medical conditions.-- Medical conditions that may be associated with anorexia, such as decreased food intake, or increased metabolic requirements should be assessed. Increased metabolic requirements may be precipitated by fever, infection, or the presence of chronic skin wounds. Anorexia may be associated with illness, drugs, dementia, or mood disorders (14) (15) (16). Decreased food intake may result from dysphagia (17), chewing problems (18), nausea, vomiting, diarrhea, pain, or fecal impaction. Treatment of these conditions may restore appetite and body weight.

Hydration.-- Fluid intake and hydration status may affect body weight. An assessment of hydration status may account for weight loss due to low fluid intake. Dehydration may be difficult to detect by clinical signs alone and require the use of biochemical parameters (19). The recommended amount of fluid consumed by nursing home residents is confusing. Amounts range from 1 mL/kcal (20), 30 mL/kg body weight (21), or the sum of 100 mL fluid per kg for the first 10 kg actual body weight, 50 mL fluid per kg for the next 10 kg actual body weight, and 15 mL fluid per kg for the remaining kilograms actual body weight (22). Direct observations of institutionalized adults indicate a total fluid intake, including fluids derived from meals, of 1,783 ± 545 mL (19). When compared to the standard of 1 mL/kcal and 30 mL/kg, recommended intakes were low, primarily due to low body weight or low caloric intake. The calculated value provides at least 1500 mL daily, even for residents with low weight. A general recommendation suggests that residents should ingest 1500 to 2000 mL of fluid per day (23), though a recent study and accompanying editorial have suggested that community-dwelling adults consume about 1000 mL per day (24) (25).

Laboratory parameters.-- Evaluation of available biochemical parameters associated with malnutrition should be considered at this point. Suggested biochemical parameters include serum albumin (26), cholesterol (27), hemoglobin, and serum transferrin. While these parameters may be abnormal in several conditions unassociated with malnutrition, they are useful as guides to intervention (28). Abnormalities in laboratory parameters should be treated.

Environmental factors.-- Food and environmental conditions that may affect intake should be considered in a continuing evaluation. Unpalatability due to overly restricted diets may cause decreased intake (29). Consideration of food preferences, food consistency (30) (31), food temperature, and snacks should be included. Provision of pleasant, well-lighted, unhurried mealtimes in a social environment may increase intake (32). Dependency in eating is associated with increased mortality (33). Residents needing feeding assistance require a restorative feeding program (32). Recognition of feeding problems and proper feeding techniques may improve weight loss in nursing homes. Dysphagia and swallowing disorders, with or without recurrent aspiration, require swallowing interventions, alteration of food consistency, or consideration of enteral or parenteral feeding (34).

Nursing Nutritional Checklist.-- The Nursing Nutritional Checklist (see Fig. 2) is designed as a supplement to the Clinical Guide to focus the comprehensive nutritional evaluation and introduce suggestions for implementing a plan of care. Notification of the results of the initial assessment to the attending physician, based on the Nursing Nutritional Checklist, should occur at this point. This checklist can be used as a communication tool to the attending physician and other members of the interdisciplinary team and may be faxed, mailed, or made available to the attending physician during nursing home visits.

Interventions.-- Continued interventions by the facility staff should occur. Early interventions include family involvement, with visits or assistance with feeding at mealtimes (35), exploration of alternate food sources, evaluation of food preferences, and identification of favorite foods. Increased nutrient intake may be achieved by use of calorie-dense foods (36). Exercise may increase dietary intake (37) (38) (39). Nutritional supplementation can increase dietary intake and produce weight gain (40) (41). Nutritional supplementation must be given between meals in order not to substitute for calorie intake at meals.

Failure to improve.-- Failure to improve nutritional status with these measures requires consideration of enteral or parenteral feeding and hospitalization for more complete evaluation (42). The resident's wishes and advanced directives may lead to a decision for palliative care.

The Clinical Guide for Physicians, Pharmacists, and Dietitians
The Clinical Guide for physicians, pharmacists, and dietitians focuses on differential diagnosis. Intervention at this point should include weekly weight assessments and a differential diagnostic approach. A mnemonic, MEALS ON WHEELS, is useful in considering the potential treatable causes of malnutrition (43). Laboratory data should be reviewed and treated as appropriate. Medical conditions reported on the Nursing Nutrition Checklist should be reviewed, including fecal impaction, infection, decline in activities of daily living associated with feeding dependency, pressure ulcer, or tube feedings.

Depression and mood disorders.-- Delirium due to acute illness and/or pain may be a reversible cause of decreased dietary intake. Reversal of delirium may result in resumption of appetite.

Depression is a major cause of weight loss in long-term care settings, accounting for up to 36% of residents who lose weight (44). An evaluation for depression, using the Geriatric Depression Scale (45) (46), for example, should be obtained for residents with anorexia (see Fig. 4).



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  		Figure 4.
 
Drugs.-- Drugs have been found to be a cause of weight loss in long-term care residents (44). In consultation with the pharmacist, all drugs potentially aggravating anorexia should be discontinued (47). Drugs that stimulate appetite (orexigenic drugs) should be considered to reverse resistant anorexia (48) (49) (50) (51). Yeh and colleagues (52) found that megestrol acetate increased weight in nursing home residents.

Irreversible causes.-- Certain causes of malnutrition may be irreversible. Palliative care, including orexigenic drugs, enteral or parenteral feeding, consistent with the resident's wishes, should be considered (53).


   Summary
Top
 Abstract
 Methods
 The Clinical Guidelines
 Summary
References
 
A structured approach to the management of unintended weight loss or malnutrition in long-term care helps to facilitate a comprehensive resident evaluation. The Clinical Guide to Prevent and Manage Malnutrition in Long-Term Care is based on a best-evidence approach to the management of nutritional problems in long-term care. While the Clinical Guide is presented in a linear fashion, many of the considerations can be done simultaneously and the order varied dependent on the individual resident's needs.

Further research to validate the effectiveness of using the algorithm in long-term care settings will be required. Prospective evaluation of outcomes using the Clinical Guide will be necessary to validate improvement in nutritional care and document its usefulness.


   Acknowledgments
 
Members of the Council for Nutritional Strategies in Long-Term Care: John E. Morley, MB, BCh, chair; William J. Evans, PhD, moderator; Wendy Ashmen, facilitator; Maude A. Babington, PharmD, FASCP; Marianne Smith Edge, MS, RD, LD, FADA; Malcolm Fraser, MD, CMD; Morris Green, MD, PhD; Clare Hendrick, RN, BSN, CRNP; Barbara L. Hoffmann, MD, CMD; Donna A. Israel, PhD, RD, LD, LPC; Steven Levenson, MD, CMD; Armon B. Neel, Jr., PD, CGP, FASCP; Dan Osterweil, MD, CMD; Cindy Pavelka, RN, BSN; Mary Ellen Posthauer, RD, CD; Miriam B. Rodin, MD, PhD, CMD; Debra Smith, RPh, FASCP; Dennis Stone, MD, MBA, CMD; Dennis H. Sullivan, MD; David R. Thomas, MD, CMD, FACP; Roy Verdery, MD, PhD; Shing-shing Yeh, PhD, MD. Council Members Representing the American Dietetic Association: Ann Gallagher, RD, LD; and Gretchen E. Robinson, MS, RD, LD, FADA.

The Gerontological Society of America Review Committee: Laurence Rubenstein, MD, MPH, Committee Chair; Connie Bales, PhD, RD; Carolyn Blaum, MD; Ronni Chernoff, PhD; and Jeanie Kayser-Jones, RN, PhD, FAA.

Received September 14, 2000

Accepted October 5, 2000


   References
Top
 Abstract
 Methods
 The Clinical Guidelines
 Summary
 References
 

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