This article was downloaded by: [McMaster University] On: 23 December 2014, At: 05:23 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
Journal of Nutrition For the Elderly Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/wjne20
Documenting MalnutritionLorraine E Matthews MS, RD
a
a
Institutional Food Service Director, City of Philadelphia Published online: 18 Oct 2008.
To cite this article: Lorraine E Matthews MS, RD (1991) Documenting Malnutrition-, Journal of Nutrition For the Elderly, 10:4, 91-96, DOI: 10.1300/J052v10n04_06 To link to this article: http://dx.doi.org/10.1300/J052v10n04_06
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content.
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This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sublicensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
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NUTRlTION MANAGEMENT IN LONG TERM CARE
Documenting Malnutrition :Checking How We Measure Up
A*
Lorraine E. Matthews, MS, RD
In a previous article in this space, the question of the inevitability of malnutrition in long term care was discussed (Matthews, 1989). Food and nutrition professionals in the long term care setting were urged to take an aggressive look at malnutrition in their own facilities. Believing that one should "put one's money where one's mouth is," the author and her staff took a hard look at their facility and the incidence of malnutrition. The process and findings of this exercise are provided below. Lorraine E. Matthews is Institutional Food Service Director for the city of Philadelphia. In this capacity, she is operational director of food service at the Philadelphia Nursing Home and food service consultant to all other city institutions. Special thanks to Lizabeth Batzel and Barbara Smale, Coordinated Undergraduate Program in Dietetics, lmmaculata College, for spending all those hours reviewing medical records and visiting residents. Journal of Nutrition for the Elderly, Vol. 10(4) 1991 O 1991 by The Haworth Press. Inc. All rights reserved.
91
92
JOURNAL OF NUTRITION FOR THE ELDERLY
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DESCRIPTION OF THE FACILITY The author's facility is a state-licensed 500-bed county nursing home providing both skilled and intermediate care. As the public facility, the institution does accept a wide variety of chronically ill and disabled people including people with a diagnosis of Acquired Immune Deficiency Syndrome (A.I.D.S.). While the majority of residents are elderly, approximately 40 percent are under 65 years of age. Currently the age range spans eighty years.
REWE W OF FACTORS THAT CAN BRING ABOUT MALNUTRITION
Condition upon Admission. The incidence of malnutrition during hospitalization is well documented and is of special concern with elderly patients. The author's facility frequently admits residents who present with some degree of malnutrition or conditions that put them at greater risk of developing malnutrition. The clinical dietitian and the dietary manager who assists her are well aware of this and work aggressively to assess newly admitted residents, document their findings, and set up meal plans that will meet their needs. Menus That Provide Adequate Nourishment. To meet the needs of such a wide age range, the institution's menus have been sct up to include a mean caloric level of 2500 calories daily (three meals and evening snack) unless contraindicated by the physician's diet order. Protein levels average between 90 and 100 g per day. The institution uses a non-selective 5-week cycle menu; however, alternates are provided at all meals and residents may choose from a number of sandwiches, platters, and other types of snacks on a daily basis. Resident Acceptance. It is virtually impossible to get 100 percent acceptance of all foods all the time; however, resident input into food choices is very important. Periodical Quality Assurance (QA) food acceptance monitors, food temperature and appearance monitor, and a very vocal Resident's Council let food service staff know when certain foods are not favored. Although the facility operates
Nutrition Management in Long Term Care
93
on a very tight budget, residentconcerns about food are taken very seriously. While this institution is certainly not without problems, the food and nutrition staff felt that they were meeting the major issues regarding resident food choices and service.
Downloaded by [McMaster University] at 05:23 23 December 2014
DOCUMENTATION OF MALNUTRITION
To further look at the incidence of malnutrition, a QA monitor was set up to look at a number of parameters. The monitor included: Ideal Body Weight (IBW) plus or minus 10% Calculation of Basal energy Expenditure (BEE) Monthly Weights for the past 6 months Percent of Weight Change, if any Calculation of Percent of IBW Status Laboratory Data for the past 2 months including Hemoglobin (HGB), Hematocrit (HCT), Total Lymphocyte Count (TLC), and Albumin, if available Age and Sex of Resident Prescribed Diet Prescribed Supplements including Oral Supplements, Multivitamins, and Iron Preparations Presence of Pressure Sores and Description of Size Estimation of Individual Resident Intake It was'decided that a current weight of less than 85 percent of IBW would be usedas an indicator of malnutrition. Some might view 85 percent as too low; however, it was the feeling of the staff, that some,of the very elderly residents, especially the females, have weighed between 85 ,and 90 percent of IBW for years (based on commonly used assessment charts) and are ambulatory and quite stable. Their inclusion would not give a true picture of the incidence of malnutrition. Data was collected by. senior dietetic students from an area college who were on a rotation at the facility.
JOURNAL OF NUTRITION FOR THE ELDERLY
INCIDENCE OF MALNUTRITION
Downloaded by [McMaster University] at 05:23 23 December 2014
AND DISCUSSION OF THE PROBLEM Initially, 81 residents from a census of 403 fit the established definition of being malnourished for a rate of 20 percent. However, nine of the 81 were residents with diagnoses of A.I.D.S. and related conditions. Unfortunately, all of these nine residents were in the terminal stages of their disease upon admission and most of the care was palliative. While certainly of major concern in terms of nutritional care, it was decided that for the purposes of this study they should be excluded from the final figures. Therefore, 72 residents, or 18 percent of 394 residents, were studied further. Not surprisingly, there was considerable overlap among the various factors. The persons with the most severe pressure sores had higher BEE'S, lower laboratory values, and poor oral intake even though the prescribed diet may have been adequate. In general, more of the residents exhibiting some malnutrition were older. It was decided to break them into groups of those over 65 and those under 65 years of age and then look at other major factors that appeared to be contributing to malnutrition. As Table 1 demonstrates, these turned out to be hemoglobin and hematocrit levels, the presence of severe pressure sores, and actual oral intake. It was also determined that the two age groups could be further broken down by the presence or absence of pressure sores. A severe pressure sore can put a major stress on the body and can impair nutritional status. In calculating calorie and protein needs, the clinical dietitian uses an injury factor of 1.5 for pressure sores of stage 2 or worse. While pressure sores can impact negatively on nutritional status; conversely, pressure sores will not heal when the resident is malnourished. Of course, the major factor in malnutrition is food intake. Fortyfive residents had intakes of 50 percent or less at the meals observed. In most of these cases, poor intake was also documented in the medical record. Very sick people often simply do not eat well even with regular prompting from care staff. Although a variety of good tasting puddings, milkshakes, and other nutrient dense foods are offered, the resident may not eat them. This can be due to a variety of problems such as depression, dementia, or physical prob-
Downloaded by [McMaster University] at 05:23 23 December 2014
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JOURNAL OF NUTRITION FOR THE ELDERLY
lems; however, this is the challenge to the care staff-to get that resident to eat. While intubation should not be the goal for every resident who doesn't eat well, neither should the facility wait too long to introduce a gastrostomy or naso-gastric feeding. Interestingly, in the groups who ate more than 50 percent of their diet, 18 of the 27 were fed via tube. Also, while their weights still had not reached 85 percent of IBW, they had actually gained weight and were exhibiting improved nutritional status.
SUMMARY The results of this monitor was shared not only with the clinical dietitian and the dietary manager, who both already had a pretty good idea of the problems involved, but also with the first line food service supervisors and food service workers. They also need to be aware that what they do has a big impact on resident care. Unfortunately, sometimes this isn't always so easy for them to see. While the staff was pleased to see that the facility's malnutrition rate was much lower than the 59 percent reported in some studies, especially considering the acuity level of the residents, nevertheless, they agreed that even 18 percent is not acceptable. The monitor was of value in a number of ways. First, it pointed out residents and areas where additional emphasis on nutrition care was needed. Secondly, it demonstrated some of the complexities involved in caring for residents with multi-faceted problems. Finally, it demonstrates the absolute necessity for a functioning clinical nutrition staff in a long term care facility.
REFERENCE Matthews, L.E., Malnutrition in the Nursing Home: Is It Inevitable? Journal of Nuldion for the Elderly. Vol. 9(1), 1989.
Journal of Nutrition For the Elderly Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/wjne20
Documenting MalnutritionLorraine E Matthews MS, RD
a
a
Institutional Food Service Director, City of Philadelphia Published online: 18 Oct 2008.
To cite this article: Lorraine E Matthews MS, RD (1991) Documenting Malnutrition-, Journal of Nutrition For the Elderly, 10:4, 91-96, DOI: 10.1300/J052v10n04_06 To link to this article: http://dx.doi.org/10.1300/J052v10n04_06
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content.
Downloaded by [McMaster University] at 05:23 23 December 2014
This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sublicensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
Downloaded by [McMaster University] at 05:23 23 December 2014
NUTRlTION MANAGEMENT IN LONG TERM CARE
Documenting Malnutrition :Checking How We Measure Up
A*
Lorraine E. Matthews, MS, RD
In a previous article in this space, the question of the inevitability of malnutrition in long term care was discussed (Matthews, 1989). Food and nutrition professionals in the long term care setting were urged to take an aggressive look at malnutrition in their own facilities. Believing that one should "put one's money where one's mouth is," the author and her staff took a hard look at their facility and the incidence of malnutrition. The process and findings of this exercise are provided below. Lorraine E. Matthews is Institutional Food Service Director for the city of Philadelphia. In this capacity, she is operational director of food service at the Philadelphia Nursing Home and food service consultant to all other city institutions. Special thanks to Lizabeth Batzel and Barbara Smale, Coordinated Undergraduate Program in Dietetics, lmmaculata College, for spending all those hours reviewing medical records and visiting residents. Journal of Nutrition for the Elderly, Vol. 10(4) 1991 O 1991 by The Haworth Press. Inc. All rights reserved.
91
92
JOURNAL OF NUTRITION FOR THE ELDERLY
Downloaded by [McMaster University] at 05:23 23 December 2014
DESCRIPTION OF THE FACILITY The author's facility is a state-licensed 500-bed county nursing home providing both skilled and intermediate care. As the public facility, the institution does accept a wide variety of chronically ill and disabled people including people with a diagnosis of Acquired Immune Deficiency Syndrome (A.I.D.S.). While the majority of residents are elderly, approximately 40 percent are under 65 years of age. Currently the age range spans eighty years.
REWE W OF FACTORS THAT CAN BRING ABOUT MALNUTRITION
Condition upon Admission. The incidence of malnutrition during hospitalization is well documented and is of special concern with elderly patients. The author's facility frequently admits residents who present with some degree of malnutrition or conditions that put them at greater risk of developing malnutrition. The clinical dietitian and the dietary manager who assists her are well aware of this and work aggressively to assess newly admitted residents, document their findings, and set up meal plans that will meet their needs. Menus That Provide Adequate Nourishment. To meet the needs of such a wide age range, the institution's menus have been sct up to include a mean caloric level of 2500 calories daily (three meals and evening snack) unless contraindicated by the physician's diet order. Protein levels average between 90 and 100 g per day. The institution uses a non-selective 5-week cycle menu; however, alternates are provided at all meals and residents may choose from a number of sandwiches, platters, and other types of snacks on a daily basis. Resident Acceptance. It is virtually impossible to get 100 percent acceptance of all foods all the time; however, resident input into food choices is very important. Periodical Quality Assurance (QA) food acceptance monitors, food temperature and appearance monitor, and a very vocal Resident's Council let food service staff know when certain foods are not favored. Although the facility operates
Nutrition Management in Long Term Care
93
on a very tight budget, residentconcerns about food are taken very seriously. While this institution is certainly not without problems, the food and nutrition staff felt that they were meeting the major issues regarding resident food choices and service.
Downloaded by [McMaster University] at 05:23 23 December 2014
DOCUMENTATION OF MALNUTRITION
To further look at the incidence of malnutrition, a QA monitor was set up to look at a number of parameters. The monitor included: Ideal Body Weight (IBW) plus or minus 10% Calculation of Basal energy Expenditure (BEE) Monthly Weights for the past 6 months Percent of Weight Change, if any Calculation of Percent of IBW Status Laboratory Data for the past 2 months including Hemoglobin (HGB), Hematocrit (HCT), Total Lymphocyte Count (TLC), and Albumin, if available Age and Sex of Resident Prescribed Diet Prescribed Supplements including Oral Supplements, Multivitamins, and Iron Preparations Presence of Pressure Sores and Description of Size Estimation of Individual Resident Intake It was'decided that a current weight of less than 85 percent of IBW would be usedas an indicator of malnutrition. Some might view 85 percent as too low; however, it was the feeling of the staff, that some,of the very elderly residents, especially the females, have weighed between 85 ,and 90 percent of IBW for years (based on commonly used assessment charts) and are ambulatory and quite stable. Their inclusion would not give a true picture of the incidence of malnutrition. Data was collected by. senior dietetic students from an area college who were on a rotation at the facility.
JOURNAL OF NUTRITION FOR THE ELDERLY
INCIDENCE OF MALNUTRITION
Downloaded by [McMaster University] at 05:23 23 December 2014
AND DISCUSSION OF THE PROBLEM Initially, 81 residents from a census of 403 fit the established definition of being malnourished for a rate of 20 percent. However, nine of the 81 were residents with diagnoses of A.I.D.S. and related conditions. Unfortunately, all of these nine residents were in the terminal stages of their disease upon admission and most of the care was palliative. While certainly of major concern in terms of nutritional care, it was decided that for the purposes of this study they should be excluded from the final figures. Therefore, 72 residents, or 18 percent of 394 residents, were studied further. Not surprisingly, there was considerable overlap among the various factors. The persons with the most severe pressure sores had higher BEE'S, lower laboratory values, and poor oral intake even though the prescribed diet may have been adequate. In general, more of the residents exhibiting some malnutrition were older. It was decided to break them into groups of those over 65 and those under 65 years of age and then look at other major factors that appeared to be contributing to malnutrition. As Table 1 demonstrates, these turned out to be hemoglobin and hematocrit levels, the presence of severe pressure sores, and actual oral intake. It was also determined that the two age groups could be further broken down by the presence or absence of pressure sores. A severe pressure sore can put a major stress on the body and can impair nutritional status. In calculating calorie and protein needs, the clinical dietitian uses an injury factor of 1.5 for pressure sores of stage 2 or worse. While pressure sores can impact negatively on nutritional status; conversely, pressure sores will not heal when the resident is malnourished. Of course, the major factor in malnutrition is food intake. Fortyfive residents had intakes of 50 percent or less at the meals observed. In most of these cases, poor intake was also documented in the medical record. Very sick people often simply do not eat well even with regular prompting from care staff. Although a variety of good tasting puddings, milkshakes, and other nutrient dense foods are offered, the resident may not eat them. This can be due to a variety of problems such as depression, dementia, or physical prob-
Downloaded by [McMaster University] at 05:23 23 December 2014
0 a , .
for
ffl, "a, 25'
1
: m ; : I
aP.1 ,I I
In
In 1 >
*0 z0
Downloaded by [McMaster University] at 05:23 23 December 2014
%
JOURNAL OF NUTRITION FOR THE ELDERLY
lems; however, this is the challenge to the care staff-to get that resident to eat. While intubation should not be the goal for every resident who doesn't eat well, neither should the facility wait too long to introduce a gastrostomy or naso-gastric feeding. Interestingly, in the groups who ate more than 50 percent of their diet, 18 of the 27 were fed via tube. Also, while their weights still had not reached 85 percent of IBW, they had actually gained weight and were exhibiting improved nutritional status.
SUMMARY The results of this monitor was shared not only with the clinical dietitian and the dietary manager, who both already had a pretty good idea of the problems involved, but also with the first line food service supervisors and food service workers. They also need to be aware that what they do has a big impact on resident care. Unfortunately, sometimes this isn't always so easy for them to see. While the staff was pleased to see that the facility's malnutrition rate was much lower than the 59 percent reported in some studies, especially considering the acuity level of the residents, nevertheless, they agreed that even 18 percent is not acceptable. The monitor was of value in a number of ways. First, it pointed out residents and areas where additional emphasis on nutrition care was needed. Secondly, it demonstrated some of the complexities involved in caring for residents with multi-faceted problems. Finally, it demonstrates the absolute necessity for a functioning clinical nutrition staff in a long term care facility.
REFERENCE Matthews, L.E., Malnutrition in the Nursing Home: Is It Inevitable? Journal of Nuldion for the Elderly. Vol. 9(1), 1989.
