- Recognition
Patients in long term care facilities are at risk for numerous conditions that can cause weight loss (see "Conditions often associated with anorexia or weight loss" below). For this reason, long term carte facilities should establish procedures to identify altered nutritional status (ANS) as early as possible.
Conditions often associated with anorexia or weight loss:
- Dementia/delirium
- Depression
- Chronic pain
- Constipation
- Use of multiple medications
- Chronic infections
- End-stage major organ system disease
- Terminal illness
Step 1
Perform a baseline evaluation of the patient's nutritional status. Because nutritional status is often compromised by events (such as hospitalization) that precede admission to a long term care facility, it is important to evaluate nutritional status as soon as possible after an individual's admission. Record the following information in the patient's chart within 14 days of admission.
- Admission weight. For best results, try to weigh
the patient on the same scale, at the same time of day, and without clothing
or shoes. Preferably, the patient should be weighed in the morning before
breakfast. However, checking weight when the patient is having a bath or
shower is acceptable. A good option is to identify a Height and Weight Team,
who become responsible for assuring the timeliness and accuracy of the
measurements. Weigh the patient weekly for the first 4 weeks to establish a
baseline. If the patient's weight is stable, weigh the patient monthly
thereafter for routine monitoring. It is advisable to calibrate or check the
calibration of the scale on at least a monthly basis. Consider calibrating the
scale anytime it is moved.
- Height and body mass index (BMI). Each facility should adopt a standard method for measuring the height of individuals who cannot stand upright. Self or family report is inaccurate, tending to overestimate height. No single method is optimal. The arm span, knee height, and recumbent height methods (described in the original guideline document) provide acceptable alternatives to measurement of standing height; the team approach assures consistency. When a special height-measurement method is used, document this in the patient's chart.
- Arm span: Measured from finger tip to fingertip with
the arms fully extended, or double the distance from extended fingertip to
mid-sternum
- Knee height: A derived estimate based on the
measured distance from heel to knee, with the foot and knee at 90 degrees
- Recumbent height: Measured using a flexible tape with the patient lying flat in bed. This measurement is approximately 1.5 inches (3.7 cm) greater than standing height.
Use of the body mass index (BMI) in the evaluation of nutritional status is strongly recommended. The BMI is calculated using the following formula:
BMI = weight (kg)/height (m2)
OR [weight (lbs)/height (in2)] x 704
- Severely underweight: <19
- Underweight: 19-23
- Desirable: 23-25
- Overweight: 25-30
- Obese: >30
- Eating preferences. As soon as practicable
after admission (if possible within 24 hours), obtain the following
information from the patient or the patient's family.
- What kinds of food does the patient usually like to
eat?
- What size portion does the patient prefer at each
meal?
- How many meals does the patient usually eat in a
day?
- At what times of day does the patient usually eat his or her meals?
Within the first 3 to 5 days after admission, staff should observe the patient eating and document the percentage of food on the plate that the patient consumes. An estimate of the percentage of food eaten by serving portion or by food group - meat, vegetables, fruit, grain products, dairy products, sweets - is preferable to a global estimate because it will help the dietitian tailor meals to match the patient's preferences.
- Baseline testing. Albumin and cholesterol
levels and a complete blood count with differential can provide a baseline for
comparison if weight change occurs later. If these values are not noted in the
patient's hospital records, the physician may consider obtaining baseline
values during the first week of admission to the facility.
However, testing to obtain these values, like other diagnostic interventions, is not appropriate for all patients. The following are questions that the physician should ask in determining whether such testing is appropriate:
- Does the patient have an advance directive? If so,
does the advance directive address the patient's wishes regarding diagnostic
tests?
- Is the goal of care maintenance or cure?
- Is the patient's care plan focused on end-of-life care?
- Minimum Data Set (MDS). Potential
predisposing factors for malnutrition in MDS-Version 2.0:
- G1h Inability to feed oneself
- K1a chewing problems: mouth, teeth, dentures
- K1b swallowing problems: pain, choking
- K3a Significant weight loss
- K4a Presence of taste alterations
- K4c Leaves 25% of food at most meals
- K5c Mechanically altered diet
- K5d Syringe (oral feeding)
- K5e Therapeutic diets
Because facilities use computerized data entry to complete the MDS form, these items can be extracted by means of a data searching program.
As in the case with the use of selected MDS items used to approximate the Braden Scale for pressure ulcer risk, using the MDS to assess nutritional status helps shape the care plan and can be a tool for monitoring change. If the MDS is used in this way, it is recommended that the relevant MDS items also be incorporated into the admission evaluation. Facilities not now using a data searching program may wish to ask their computer software vendor whether such a program is available.
Step 2
Identify risk factors for altered nutritional status. Seek information about the presence of each of the following risk factors for all newly admitted patients.
- History of recent weight loss or change in appetite. If the patient is competent, ask whether he or she has lost weight recently or has had a loss of appetite. Also ask the patient's family and, if appropriate, consult the patient's hospital discharge records. A "yes" response from any source should trigger closer observation of the patient. Nutrition Care Alerts can help remind staff of signs and symptoms that might identify a change in nutritional status.
- Functional disability. Within the first 3
to 5 days after admission, a staff member should observe the patient eating
and document the following:
- Ability to feed himself or herself without assistance; degree and nature of assistance needed, if any (e.g., help
with meal set-up, cutting of meats, verbal prompts, adaptive devices).
- Upper-extremity impairments of mobility and coordination while eating. Pay particular attention to tremors, ataxia,
and signs of weakness.
- Body positioning. Desirable positioning means
the patient is seated with hips at approximately 90 degrees, close to the
table, with approximately 12 inches from plate to mouth.
- Ability to grasp the eating utensils, lift them to the mouth, and use them appropriately.
- Difficulty chewing or swallowing food.
- Assess the patient for tongue lesions, mouth
sores, dental caries, gum disease, or poorly fitting dentures.
- Assess gag reflex, tongue movement and strength,
ability to handle saliva, and other obvious impediments to chewing or
swallowing.
- Look for signs that may indicate dysphagia, such
as:
- coughing before, during, or after swallowing
- need to swallow 3-4 times with each bolus
- frequent throat-clearing
- hoarse, breathy, or wet voice; gargling while
breathing
- sensation of something caught or stuck in the
throat; drooling; pocketing food in the cheeks
- oral-buccal akathisia (protruding tongue movements)
A skilled individual such as a physician, registered nurse, or speech pathologist (see Table 5 in the original guideline document for elements of a bedside clinical evaluation of a swallowing problem) should perform a bedside clinical evaluation to distinguish true dysphagia (difficult or impaired swallowing) from other related symptoms (for example, a chewing or dental problem or a cough of nasal or pulmonary origin). If the existence of a swallowing problem is confirmed on clinical grounds, then determine whether further testing is relevant to that individual's goals and prognosis and whether it would add materially to what is already known or would change the ultimate treatment decisions, for example:
- Does the patient have an advance directive? If so,
does the advance directive address the patient's wishes regarding diagnostic
tests?
- Is the goal of care maintenance or cure?
- Is the patient's care plan focused on end-of-life care?
Before a fluoroscopic cine-esophagram is ordered, the interdisciplinary team (including the attending physician), speech pathologist, and the patient (if he or she is competent) or a family member should discuss the appropriateness of this test. If it is decided to proceed with the test, document in the patient's chart the reasons for the test and the expected benefits.
- Presence of an active pressure ulcer. Evaluate all
patients with pressure ulcers to determine their nutritional status and
ability to consume sufficient calories to meet their needs.
- Presence of a terminal illness. Even among
terminally ill patients, for whom invasive interventions are rarely warranted,
changes in diet can improve intake and satisfaction.
- Depression. In addition to closely observing
patients' weight and food intake for the first 4 weeks after admission, staff
should monitor all newly admitted patients for other signs that may indicate
depression (see American Medical Directors Association [AMDA] guidelines on depression).
- Medication use. Document all medications the
patient is taking, noting especially any new medications prescribed during his
or her hospital stay. Ask the patient or family whether the patient takes any
over-the-counter products not listed in the medical record. It is often
helpful for the physician and a clinical pharmacist to review the medication
regimen, paying specific attention to medications associated with ANS. Refer
to Table 6 in the original guideline document for a list of medications that
may be associated with altered nutritional status
- Presence of nausea, vomiting, or diarrhea. These symptoms may indicate medication side effects or a gastrointestinal, hepatobiliary, or renal disorder. Medications commonly associated with these symptoms include digoxin, antibiotics, and non-steroidal anti-inflammatory drugs (NSAIDs). Antibiotics may also cause Clostridium difficile colitis.
- Presence of fluid retention and edema. Weight
monitoring should focus on dry weight, especially in patients with cardiac,
renal, or hepatic disease, in whom weight gain can be important early signs of
impending decompensation.
- Presence of underlying infection.
Refer to the original guideline document for further discussion of factors listed above.
Step 3
Observe the patient routinely for changes in weight or food intake that may indicate ANS. At any time during a patient's stay in long term care, observation of
any one of the following conditions should trigger a prompt initiation of an
assessment of the patient's nutritional and fluid status (Step 5):
- Weight change of 5% in 1 month, 7.5% in 3 months, or
10% in 6 months (Resident Assessment Protocol [RAP] criteria).
- Decline in food intake over several days (not to
exceed 7 days). An abrupt change, such as refusal of food for two or more
successive meals, usually indicates a medication side effect or the presence
of an acute illness rather than a nutritional problem.
- BMI drifting to <19. Establish if BMI <19 is
normal for this individual or whether he or she has slowly lost weight. People
who are constitutionally thin may need closer monitoring and more narrow
triggering criteria, although they are within their normal weight range,
because their physiologic reserves are low.
- Persistent, unexpected and unintended weight loss for 3 consecutive months. Without a detailed history, this may be difficult to assess on admission, but it is an easily appreciated and far more sensitive trigger than the RAP criteria.
- Assessment
The following steps are intended to guide the diagnostic assessment of the patient who triggers one or more of the ANS criteria from Step 3. The diagnostic process has been divided into two tiers.
- Tier I is intended to identify causes of
nutritional problems that are common, easily identified, and reversible in
some cases. It should be completed within 30 days of recognition of ANS.
- Tier II is intended to identify uncommon
conditions, or diagnoses for which cure is less likely. These conditions are
important because they may affect prognosis, alter the goals of care, and
redirect the care plan. A Tier II Assessment is not appropriate in all
cases; some patients and families may choose to forego this assessment for
personal reasons. If a Tier II Assessment is undertaken, it should be
completed within 90 days, but no more than 120 days of recognition of ANS.
By this time, the decision to insert a percutaneous endoscopic gastrostomy
(PEG) tube or pursue a palliative care plan should be clarified, if the
patient has not stabilized.
Steps within tiers are meant to be concurrent rather than sequential. They represent complementary aspects of a comprehensive, interdisciplinary review. Weight loss and weight gain follow separate but occasionally overlapping tracks.
Tier 1 Assessment. These steps are intended
to identify causes of a nutritional problem that are common, easily
identified, and potentially reversible. Each discipline has a role in the
assessment within its sphere of knowledge and a responsibility to share its
findings with the team. Because multiple factors usually contribute to a
nutritional problem, the assessment should not stop with the first or most
obvious cause. Other less apparent causes may be equally important and, when
treated, may lead to improvement or resolution of the problem. The Tier I
Assessment should be completed and recorded in the patient's chart as soon
as practicable, but no more than 30 days after recognition of
ANS.
Step 4
Confirm the existence of a problem that requires additional assessment.
- Validate weight measurements before initiating an
interdisciplinary assessment of ANS.
- Evaluate whether the patient's weight change (loss or
gain) is truly unintended or unexpected.
- Evaluate the patient's willingness to undergo a diagnostic assessment.
If this review confirms the presence of a problem that requires additional assessment, mobilize the interdisciplinary team to help identify the underlying causes of the problem and develop a treatment plan. If the Step 3 assessment criteria are met but the patient or family decides not to intervene, this decision and the rationale for it should be clearly documented in the patient's record. (See Step 13.) For the patient who triggers an assessment because of weight gain, skip to Step 10.
Step 5
For a patient who has lost weight: Establish that the patient is eating the food he or she receives. Monitor the patient's food intake for at least 1 day (some dietitians prefer a 3-day evaluation). A simple estimate of the
fraction of each portion or food from each food group consumed at each meal
is usually sufficient; a calorie count is not necessary. Refer to the
original guideline document for a discussion of anorexia, weight loss that
occurs despite normal intake, and hyperphagia.
Step 6
For patients whose food intake is inadequate: Screen for functional impairments.
- Observe the patient while he or she is eating. Pay
attention to tremors, ataxia, signs of upper extremity weakness, joint pain,
conditions that limit mobility, body positioning, and ability to grasp the
eating utensils and lift them to the mouth.
- Evaluate the patient for oral pain caused by tooth
decay or gum pathology. Do dentures fit properly? Is the food of a consistency
that the patient can chew and swallow?
- Observe the patient's swallowing ability. Assess
tongue strength and movement, the presence of coughing and other signs of
dysphagia while eating, ability to differentiate tastes, and sensitivity to
hot and cold foods.
- Evaluate whether adequate feeding assistance is available and whether the time set aside for meals is sufficient for patients who eat slowly.
Step 7
For patients whose food intake is inadequate: Screen for social and environmental factors, dietary restrictions, and food preferences.
- Reassess the patient's food preferences. Ask the
patient's family to bring in foods the patient likes. Try to individualize the
patient's meal plan. (See Step 17.)
- Review the necessity for any dietary restrictions.
Routine dietary restrictions are usually unnecessary in the long term care
setting. (See Step 18.)
- Evaluate the environment in the room where patients eat their meals. Noise and distractions may deter some patients from eating an adequate amount of food. On the other hand, eating alone may adversely affect mood and contribute to anorexia.
Step 8
For patients whose food intake is inadequate: Screen for medical conditions associated with anorexia or dehydration.
- Consider fluid and electrolyte imbalance. [See
American Medical Directors Association (AMDA) guideline on dehydration.]
- Look for and evaluate any changes in the patient's
mood or behavior. Consider using structured evaluations such as the Geriatric
Depression Scale for patients who are verbal or the Cornell Scale for
Depression in Dementia, which is more behaviorally based.
- Comprehensively review all medications. Refer to the
original guideline document for a discussion of medications associated with
ANS.
- Consider the presence of infections.
- Consider gastrointestinal pathology and motility
disorders.
- Order a chest X-ray and a panel of laboratory tests (see below) to screen for occult physical illness. Results of the history and physical examination may suggest additional laboratory and radiographic studies.
Tier 1 Assessment - Baseline Laboratory Tests
The following are the most readily available laboratory values to support the findings of a diagnosis resulting in ANS. However, the diagnosis of malnutrition cannot be made on the basis of either laboratory tests or anthropometrical measurements alone. Test results and measurements must be correlated with clinical findings and recent medical history.
- Appropriate drug levels
- Complete blood count with differential
- Comprehensive metabolic profile (or similar panel
including liver enzymes, total protein and albumin, calcium and phosphorus,
cholesterol and magnesium)
- Hemoccult
- Malabsorption syndromes (e.g., C. difficile assay)
- Thyroid-stimulating hormone
- Urinalysis and culture if urinalysis (UA) is positive
Pre-albumin may be useful in the laboratory assessment of the adequacy of enteral feeding prescriptions.
Step 9
For patients who lose weight despite normal intake: Screen for a malabsorption syndrome and for conditions that increase nutritional needs. Patients who lose weight despite normal
intake generally fall into one of three categories: those receiving
inadequate servings of food, those whose metabolic need is greater than
their usual level of food consumption, and those with a malabsorption
disorder.
- Inadequate caloric intake. Patients who weigh more
than 175 lb may need more than the standard 2000 kcal/day as a basal diet.
Patients who wander or fidget or suffer from chronic movement disorders may
need additional food to compensate for the energy expended in these
activities.
- Increased metabolic need. Persistent infections,
advanced illness, such as heart failure, chronic bronchitis/emphysema, liver
or renal failure, and the presence of large pressure ulcers increase metabolic
demands more than the patient's activity level might suggest.
- Malabsorption. This condition is usually but not always associated with diarrhea. Causes may include pancreatic insufficiency, dumping syndrome related to bacterial overgrowth in the small intestine, acquired lactose intolerance, partial ileus, C. difficile-related colitis (with diarrhea), or a
protein-losing enteropathy (with or without diarrhea).
Step 10
Screen patients who gain weight for conditions related to fluid retention.
Tier II Assessment
Most patients with an unexpected and unintended change in weight should undergo the Tier I Assessment described in Steps 4-10, as appropriate, with exceptions clearly documented. If this assessment fails to identify a likely cause of the weight change, a search for less common and less obvious causes should be pursued if it is consistent with the patient's and family's goals. Because it may take up to 3 months to identify a cause, an empiric nutritional interaction is often appropriate while the diagnostic evaluation continues. If a Tier II Assessment is undertaken, it should be completed within 120 days of recognition of ANS.
Step 11
For patients who have lost weight: Evaluate whether a continued search for the cause of weight loss is appropriate. The Tier II Assessment for patients who have lost
weight is more likely than the Tier I Assessment to conclude with the
discovery of an irreversible or terminal diagnosis. Important examples include
metastatic cancer; progressive dementia or other degenerative neurological
conditions; and end-stage cardiac, pulmonary, renal, and hepatic illnesses.
Unremitting weight loss in the context of these conditions should be
considered evidence of a terminal disease and progressive weight loss should
be considered unavoidable. (See Step 13)
When no terminal condition can be clearly identified, the patient's care goals and willingness to undergo more intensive medical evaluation must be considered in determining whether a continued search for the cause of weight loss is appropriate. If it is decided to continue, the interdisciplinary team should
- Repeat the patient's history and physical findings in
light of the recent weight change.
- Order additional laboratory and radiological studies based on any new findings in the "second-look" history and physical examination.
Refer to Table 9 in the original guideline document for a list of additional possible causes for weight loss.
If it is decided to halt further testing, document this decision in the patient's record. Some patients and their families may wish to forego further testing for personal reasons; these wishes should be respected.
In some cases, the physician may determine that further testing would not substantially change the treatment or outcome. In this circumstance, documentation of a second opinion by a corroborating physician or the medical director of the facility is strongly recommended. The patient, or other responsible party, should be notified, and if there is disagreement, the case presented to an Ethics Committee. Empiric oral supplementation may be tried (see Steps 19 and 20), but if the patient fails to stabilize despite these efforts, additional weight loss should be considered unavoidable. (See Step 13.)
Step 12
For patients who have gained weight: Evaluate whether a continued search for the cause of weight gain is appropriate. A Tier II Assessment is indicated for a patient who has gained weight
Step 13
Identify and document unavoidable ANS. Assessment and treatment of a nutritional problem must be consistent with the individual's care goals and must offer a benefit to the patient. Review the patient's advance directives.
For a patient with a terminal condition, a change in weight is unavoidable when one or more of the following conditions applies after a Tier II Assessment has been completed and documented, or after a decision not to proceed with a Tier II Assessment has been documented.
- The assessment has identified no remediable cause for
the patient's change in weight.
- Although the cause of the change in weight has been
identified, the patient has not responded to a therapeutic trial. (See Steps
15-19).
- Further intervention may harm the patient or offers no reasonable expectation of benefit.
For a patient who has an end-stage condition or is in a persistent vegetative state, a change in weight is unavoidable when one of the following conditions applies after a Tier II Assessment has been completed and documented, or after a decision not to proceed with a Tier II Assessment has been documented.
- The assessment has identified no remediable cause for
the patient's change in weight.
- Further intervention may harm the patient or offers no
reasonable expectation of benefit.
- The patient or family has requested that no further diagnostic or therapeutic intervention be pursued.
Step 14
Summarize the results of the assessment of the patient's ANS. This summary should:
- Identify the extent of the weight loss or gain.
- Describe all identified or probable conditions
contributing to ANS.
- Project the individual's prognosis and likely clinical course.
- Treatment
The assessment process described above is intended-to the extent that is reasonable and practical and has the patient's consent-to identify all treatable conditions and diagnose all remediable illnesses. Treatment is defined in this guideline as any intervention that offers a reasonable expectation of benefit for the patient. This may include making changes in the eating environment, offering rehabilitation for functional disabilities, and controlling or mitigating the effects of medical conditions associated with ANS. Treatment may be considered successful when the patient's weight has stabilized, even if it stabilizes at a level below baseline.
The patient does not have to regain the weight lost. Older adults tend not to return to their previous weight after an illness or temporary nutrient and fluid deficiency.
Step 15
Address each identified risk factor and potential cause of ANS identified in the Recognition and Assessment phases (see Steps 1-13). The dietary, medical, functional and nursing care plans should address identified risk factors and the associated causes identified in the diagnostic assessment. For each identified risk factor, establish a planned
intervention.
- Treat depression aggressively. Some antidepressants
may increase appetite. However, relief of the patient's depression is the
major reason for improved food intake following initiation of antidepressant
therapy.
- Reassess all medications for continued indications,
potential side effects, and interactions that may affect nutritional status.
- Evaluate the patient's activity level and ability to
exercise (exercise can stimulate appetite).
- For a verified swallowing problem, consider the underlying causes and patient prognosis and determine whether the patient is a candidate for rehabilitation. A physician should help the interdisciplinary team weigh the benefits of allowing someone to eat a less restricted diet versus any potential risks. Based on understanding the overall picture, a speech pathologist may recommend appropriate food textures and consistency, improve body positioning, and teach the patient specialized swallowing techniques such as a chin-tuck swallow and double swallowing. Or, it may be concluded that no restrictions are appropriate because it is preferable to allow the patient to eat despite aspiration risks.
Step 16
Address issues that may affect the eating environment in the nursing facility.
- Ensure that the environment in the room where meals
are served is pleasant and conducive to eating. For example, try to reduce
noise, confusion, and distractions.
- Make every effort to ensure that all foods offered are
attractive and palatable. Use garnishes, seasonings, and sweets, as
appropriate, to enhance the appearance and taste of dishes.
- Consider having more than one meal sitting. Multiple
sittings for smaller groups are preferable to separate sittings for
independent and non-independent eaters. Patients who are alert and can eat
independently may be asked to help patients who need verbal cues to encourage
them to eat.
- Adopt a flexible staffing pattern that enables nursing
staff to move to floors or units where more patients need assistance at meal
times.
- Use non-nursing staff and volunteers at meal times to
help set up trays and enhance socialization at mealtimes. This frees nursing
staff to assist patients who need the most help with eating and those who can
feed themselves if they receive verbal cues. Training of family members to
help feed selected patients is encouraged. (AMDA strongly supports the
development of certificate feeding-assistance programs for family, volunteers
and non-professional staff in accordance with state and federal guidelines.)
However, only certified nursing assistants (CNAs) and other properly trained
staff should feed patients with dysphagia and other swallowing disorders.
- Consider having a happy hour before dinner, when
residents may congregate and have an alcoholic beverage or sweets before their
meal.
- Try using the smell of freshly cooked food as an enhancement to eat. For example, consider warming foods in a crock-pot or operating a bread-making machine in the dining area.
Step 17
Tailor meals and foods to individual preferences. Each patient has a lifetime of
eating habits and food preferences based on ethnic, regional, and personal
tastes. By adopting a flexible approach to food service and presentation,
facilities can meet the challenge of satisfying these preferences in an
institutional setting.
- Individualize each patient's meal plan. Offer the
option of small, medium, and large portions at each meal. Patients may have a
preferred time to eat their main meal of the day, especially breakfast or
lunch, at which they are likely to consume a larger portion.
- Permit flexibility in the times that meals are served.
Scheduling meals and snacks at approximately 3-hour intervals between 6 a.m.
and 9 p.m. allows patients to eat at the times they prefer. Flexible meal
scheduling also has the effect of staggering through-out the day the number of
patients who need help with eating.
- Permit patients to eat at their own pace. If a patient
has stopped eating, do not immediately remove the tray. Ask the patient if he
or she has finished eating. Encourage the at-risk patient to eat a few more
bites before removing the tray.
- Invite the patient's family members to bring in foods
they know the patient likes to eat (unless the patient's diet is restricted
because of medical conditions; see Step 18).
- Offer foods that satisfy patients' ethnic, regional,
and personal preferences as well as their preferences for sweet, salty, or
spicy foods.
- Provide foods of a consistency and texture that allows
comfortable chewing and swallowing. For example, a patient who has difficulty
swallowing may reject pureed or artificially thickened foods but may eat foods
that are naturally of a pureed consistency, such as oatmeal, ice cream,
yogurt, mashed potatoes, and puddings.
- Provide adaptive devices that promote independent
eating and encourage patients who need help with feeding to use them. Adaptive
devices include swivel spoons, rocker knives, utensils with thick handles,
plates with an inner lip, and bowls with a large distal lip.
- For patients who cannot use utensils, offer finger-foods, for example, nuggets instead of fillets, french fries instead of mashed potatoes, and carrot sticks instead of a salad.
Step 18
Reconsider all dietary restrictions. Routine dietary restrictions are usually unnecessary and can be counterproductive in the long term care setting. Special diets for diabetes, hypertension and heart failure, and hypercholesterolemia have not been shown to improve control or affect
symptoms. When a patient is at risk for or has an unintended weight loss, the
presence of one of these diagnoses alone is insufficient justification for
continuing dietary restrictions. The reasons for any dietary restrictions that
are ordered should be clearly stated in the patient's record.
Late-stage renal insufficiency is an exception to this general rule; protein restriction in patients with late-stage renal insufficiency may delay the onset of dialysis. However, protein need not be restricted in patients on dialysis. Dietary restrictions may need to be removed gradually to avoid medication side effects. For example, for patients taking lithium, easing restrictions on dietary sodium may reduce lithium levels and may exacerbate the underlying illness. These patients require closer monitoring during the transition.
Diets of altered consistency (especially purees) are often unpalatable and visually unappealing and patients may reject them. To the extent possible, tailor changes in food consistency to patients' preferences and tolerance; finely chopped foods may retain their flavor and be equally well handled. Every effort should be made to season and enhance flavors of altered textured foods. Order diets of altered consistency only when a patient has a demonstrated problem or a very high risk of aspiration-for example, a patient who has recently had a stroke or laryngopharyngeal surgery.
Step 19
Consider ways to
supplement the patient's diet. If the patient does not consume sufficient food or fluids, consider options for supplementation
roughly in the following order.
- Increase the nutrient density of foods. Increase
protein content by adding milk powder, egg whites, or tofu (a bland soy-based
food). Increase fat content by adding butter, margarine, or oil during food
preparation, and sauces or gravy at meals.
- Offer snacks as part of a defined between-meal snack
program- for example, during or after a group activity.
- Consider giving a daily multivitamin and mineral
supplement to patients whose food consumption is marginal until the cause of
the inadequate intake is determined.
- Distribute liquid dietary supplements during the medication pass. Evidence suggests that a liquid supplement given approximately 60 minutes before a meal does not reduce food consumption. For example, 2 to 4 oz of a 2 kcal/cc formula given four times daily with the medication pass provides 500 to 1000 kcal/day.
Step 20
Consider the use of appetite stimulants on an individual basis. Increased exercise may be an appropriate,
non-pharmacological approach to appetite stimulation in some patients. The use
of medications (see Table 10 in the original guideline) to stimulate appetite
in long term care patients is controversial. In general, these medications
have not been adequately studied and are not part of the routine evaluation
and treatment of weight loss in the long term care setting. However, their use
may be considered on an individual basis. If initiated, appetite stimulants,
such as megesterol acetate, are not likely to have a demonstrable effect for
at least 2 months. If the patient gains weight and tolerates the regimen, the
agents should be continued for at least 12 weeks, at which point, the regimen
may be discontinued. Although weight gain, improved appetite and greater sense
of wellbeing may continue for several months, there is no evidence of improved
longevity.
Step 21
Evaluate the risks and benefits of tube feeding. Questions about advance
health care directives and attitudes about tube feeding may be included in the
patient's admission evaluation. (See Step 1.) Record this information in the
patient's chart so that it is available to guide later decision-making.
Because the patient may be incapable of expressing a choice when the need
arises, appointment of an advocate for health care decision-making is the best
means of assuring that his or her wishes are honored in the future.
Tube feeding may be clinically appropriate in certain circumstances (see "Indications for the use of a feeding tube" below). However, it should not be an automatic next step when other feeding strategies have failed. Table 12 (see "Selection and administration of tube feeding" below) gives the guidelines on the use of feeding tubes that are used by federal surveyors. Before deciding to initiate tube feeding, the interdisciplinary care team should meet with the patient and family to carefully consider the risks and benefits of tube feeding and the patient's preferences.
In general, tube feeding may be appropriate when
- There is a clear clinical indication for its use
- It provides a benefit that is not outweighed by risks
- It is consistent with the known values and preferences of the patient and family
Indications for use of a feeding tube:
- Choking prevents ingestion of a meal (aphagia)
- Difficulty swallowing prevents oral intake of
adequate calories (dysphagia)
- Stroke or other neurological disorders
- Head and neck surgery
- Esophageal obstruction
- Discontinuous gastrointestinal (GI) tract
- Patient/family preference
Selection and administration of tube feeding:
- Tube-feeding care plan reflects the wishes/advanced
directives of the resident/family
- Goals for feeding are stated and are consistent with
the tube-feeding care plan
- Residents' rights to privacy and dignity are respected
- Tube will be withdrawn when no longer needed or consistent with therapeutic goals
Refer to the original guideline document for further discussion regarding tube feedings.
Step 22
Summarize the results of treatment interventions on the patient's ANS. Weight
stabilization is the primary endpoint. Individual interventions may need to be
tried for up to 2 to 3 months before their effectiveness can be determined.
During these therapeutic trials, progress notes should briefly describe:
- The treatment plan and the patient's compliance with
it.
- Complications or side effects of interventions.
- Trends in weight lost or gained.
- The strategy for monitoring the patient's response to
the intervention and adjusting the intervention as necessary.
- The individual's prognosis and likely clinical course.
Document the resolution of the ANS episode.
Ultimately, either the patient's weight will stabilize or the lack of response
will indicate an unavoidable condition. (See Step 13.) The progress note or
discharge summary should include a synopsis of the assessment, therapeutic
plan, and outcome. If the patient's weight stabilizes at a level not
considered a healthy body weight, subsequent interventions may be considered
but are not part of this guideline.
- Monitoring
The steps involved in recognizing, assessing, and treating ANS may take place over several months. For this reason, it is recommended that one individual such as a dietitian or nursing supervisor be designated as responsible for tracking the process and its resolution for each patient who triggers an ANS evaluation. At the facility level, the Quality Assurance (QA) committee or an ANS Oversight Committee should be responsible for ensuring the continuity of the recognition, assessment, treatment, and monitoring phases through a program of continuous quality improvement.
Step 23
Monitor the effectiveness of treatment interventions. Weight stabilization is the primary endpoint. If ANS persists, reconsideration of the treatment
plan should be documented at least monthly. When the ANS episode is resolved,
the causes, interventions, and outcome should be summarized in the patient's
record.
Step 24
Monitor all patients regularly to identify ANS as early as possible. Document the
findings of periodic re-evaluations in the patient's chart.
- Following the admission evaluation, weigh the patient
weekly for the first 4 weeks. If weight is stable, weigh monthly thereafter.
For the most accurate results, always weigh the patient on the same scale, at
the same time of day (preferably in the morning before breakfast), and without
clothing or shoes. (See Step 1.)
- Implement ongoing surveillance for the ANS criteria.
(See Step 3.)
- If MDS data are used as a monitoring tool (see Step
1), complete the MDS-Version 2.0 quarterly and record these findings in the
patient's chart as a distinct entry.
- Review advance directives annually as well as
whenever a patient's clinical status changes to a degree sufficient to prompt
an MDS re-evaluation. In discussions with patients and families about advance
directives, ensure that preferences concerning nutritional interventions are
addressed.
- If baseline laboratory values (e.g., albumin and cholesterol levels and complete blood count) would be helpful in monitoring or setting care goals, consider checking these values annually.
Step 25
Monitor to ensure that each ANS risk factor identified in the admission evaluation is addressed (see Step 2). An ANS Oversight Committee or similar facility-wide oversight body should establish mechanisms for tracking the risk factors identified in the admission evaluation. Each risk factor should be linked to a planned intervention. Both implementation of the care plan by the interdisciplinary team and effectiveness of the interventions should then be monitored as part of a continuous quality improvement program.
Step 26
Monitor the incidence and prevalence of ANS in the facility. The frequency with which
the ANS criteria in Step 3 initiate an assessment can be used as an indicator
of both the severity of illness among recent admissions and the quality of ANS
prevention programs.
These criteria are:
- Weight change of 5% in 1 month, 7.5% in 3 months, or
10% in 6 months (Resident Assessment Protocol [RAP] criteria).
- Decline in the patient's food intake over several
days (not to exceed 7 days). (An abrupt change, such as refusal of food for
two or more successive meals, usually indicates a medication side effect or
the presence of an acute illness rather than a nutritional problem.)
- BMI drifting to <19. (Establish if this is a
normal state for this individual or whether he or she has slowly lost weight.
People who are constitutionally thin may need closer monitoring, although they
are within their normal weight range, because their physiologic reserves are
low.)
- Unexpected and unintended weight loss that persists for 3 consecutive months.
Step 27
Monitor the assessment process (see Steps 4-14). The ANS oversight or Quality Assurance committee should establish a mechanism for tracking the assessment
process when a patient triggers an evaluation for ANS. Compliance with Steps 4
and 5 is easily monitored and should be verified before the interdisciplinary
team proceeds with subsequent steps. Compliance with the Tier I Assessment
(Steps 6-10) may be most readily tracked by a sign-off mechanism for each
discipline represented on the interdisciplinary team. If desired, each
discipline can develop a worksheet to track completion of the elements for
which it is responsible. Verify that each discipline has fulfilled its
responsibilities before proceeding to the Tier II Assessment.
