Nutritional management in long-term care: development of a clinical guideline.

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 and the Nursing Nutritional Checklist 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.

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 the Omnibus Budget Reconciliation Act of 1987 (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 2,000 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 (less than 19 in men and less than 19.4 in women). In hospitalized adults with serious illness, excess mortality within 6 months (risk ratio 1.23, p less than .001) has been demonstrated when the BMI is less than 20. 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 less than 23.5 in men and less than 22.0 in women. 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.

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. Decreased food intake may result from dysphagia, chewing problems, 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. The recommended amount of fluid consumed by nursing home residents is confusing. Amounts range from 1 mL/kcal, 30 mL/kg body weight, 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. Direct observations of institutionalized adults indicate a total fluid intake, including fluids derived from meals, of 1,783 + 545 mL. 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 1,500 mL daily, even for residents with low weight. A general recommendation suggests that residents should ingest 1,500 to 2,000 mL of fluid per day, though a recent study and accompanying editorial have suggested that community-dwelling adults consume about 1,000 mL per day.

Laboratory Parameters

Evaluation of available biochemical parameters associated with malnutrition should be considered at this point. Suggested biochemical parameters include serum albumin, cholesterol, hemoglobin, and serum transferrin. While these parameters may be abnormal in several conditions unassociated with malnutrition, they are useful as guides to intervention. 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. Consideration of food preferences, food consistency, food temperature, and snacks should be included. Provision of pleasant, well-lighted, unhurried mealtimes in a social environment may increase intake. Dependency in eating is associated with increased mortality. Residents needing feeding assistance require a restorative feeding program. 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.

Nursing Nutritional Checklist

The Nursing Nutritional Checklist (refer to Figure 2 in the original guideline document) 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, 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. Exercise may increase dietary intake. Nutritional supplementation can increase dietary intake and produce weight gain. 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. The resident’s wishes and advanced directives may lead to 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. Laboratory data should be reviewed and treated as appropriate. Medical conditions reported on the Nursing Nutrition Checklist should be reviewed, including fecal impaction, infection, and 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. An evaluation for depression, using the Geriatric Depression Scale for example, should be obtained for residents with anorexia.

Drugs

Drugs have been found to be a cause of weight loss in long-term care residents. In consultation with the pharmacist, all drugs potentially aggravating anorexia should be discontinued. Drugs that stimulate appetite (orexigenic drugs) should be considered to reverse resistant anorexia. One study 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.

Complete Summary

GUIDELINE TITLE

BIBLIOGRAPHIC SOURCE(S)

GUIDELINE STATUS

COMPLETE SUMMARY CONTENT

DISEASE/CONDITION(S)

GUIDELINE CATEGORY

CLINICAL SPECIALTY

INTENDED USERS

GUIDELINE OBJECTIVE(S)

TARGET POPULATION

INTERVENTIONS AND PRACTICES CONSIDERED

MAJOR OUTCOMES CONSIDERED

METHODS USED TO COLLECT/SELECT EVIDENCE

DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

NUMBER OF SOURCE DOCUMENTS

METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

METHODS USED TO ANALYZE THE EVIDENCE

DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

METHODS USED TO FORMULATE THE RECOMMENDATIONS

DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

COST ANALYSIS

METHOD OF GUIDELINE VALIDATION

DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

MAJOR RECOMMENDATIONS

CLINICAL ALGORITHM(S)

TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

POTENTIAL BENEFITS

POTENTIAL HARMS

QUALIFYING STATEMENTS

DESCRIPTION OF IMPLEMENTATION STRATEGY

IMPLEMENTATION TOOLS

IOM CARE NEED

IOM DOMAIN

BIBLIOGRAPHIC SOURCE(S)

ADAPTATION

DATE RELEASED

GUIDELINE DEVELOPER(S)

GUIDELINE DEVELOPER COMMENT

SOURCE(S) OF FUNDING

GUIDELINE COMMITTEE

COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

GUIDELINE STATUS

GUIDELINE AVAILABILITY

AVAILABILITY OF COMPANION DOCUMENTS

PATIENT RESOURCES

NGC STATUS

COPYRIGHT STATEMENT

NGC DISCLAIMER

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