Improving the Nutritional Status of the Elderly Living in Long-Term Care

By: Wendy Wu, MS, RDnursing home

Malnutrition is very common in elderly people living in long-term care and is associated with significant adverse health outcomes. Important contributors of impaired nutritional status include physiological changes, psychological concerns, polypharmacy, and poor customer service from nursing staff and foodservice. It is necessary to provide nutritionally adequate, culturally appropriate food, which is acceptable to patients’ needs. Proper Staffing and implementing changes to food service has demonstrated an increase in energy intake. Social support systems and positive dining room atmosphere are strategies to enhance resident satisfaction. When these interventions are placed in effect, the nutritional status of the elderly living in long term care can be greatly improved.

Factors Affecting Nutritional Intake

  • Poor oral health is common in the aging process. Edentulism, extensive alveolar bone, residual ridge atrophy, or poor oral health reduces chewing ability and limits food selection. Residents with no teeth are more likely to consume fewer fruit and vegetables; less dietary fiber, beta-carotene, calcium, and protein; and more cholesterol and saturated fat than do their dentate counterparts. Poor dentition or use of dentures also affects the ability to perceive food flavor.
  • Dependence of eating increases after a stroke. The consequence of stroke includes different functional impairments relating to arm movement, posture, lip closure, chewing, swallowing, perception, attention and sensation. These impairments contribute to different eating disabilities which increase the need for careful observations, assessments and documentation of eating and nutrition. Difficulty with dishes, lids, and food packages are believed to increase resident’s stress during mealtime and poor utensil use contributes to low food and fluid intake in dementia patients. It is up to the nursing staff to provide the proper assistance to residents who are dependent on feeding. Under-staffing has been associated with inadequate feeding assistance during meals.
  • Loss of appetite is a major cause of malnutrition in LTC. With advancing age, humans experience a physiologic reduction in food intake designated as the “anorexia of aging”.  Anorexia of aging occurs to counterbalance the declines in physical activity and resting metabolic rate that is generally seen in the elderly. As appetite decreases, intake of total energy, protein, vitamins and minerals is reduced, depleting the body of necessary nutrients. This physiologic change places the elderly at a greater risk for malnutrition.
  • It is recognized that the elderly in LTC suffer from a higher incidence of chronic diseases. Approximately 85% of Americans 65 years of age and older have at least one chronic illness, and 60% of those over 85 years have two or more chronic illness. With multiple chronic illnesses, the elderly are very likely taking multiple medications. Anorexia, nausea, vomiting, altered taste perception and constipation are some of the side-effects of polypharmacy which may cause reduced food intake. Medications can also interfere with nutrient absorption, cause alteration in nutrient metabolism and increase nutrient excretion. As a result, they are more likely to suffer from drug-induced malnutrition.
  •  Depression is one of the most common causes of unintentional weight loss and malnutrition in older adults. It can be caused by several factors including loss of loved ones, impaired physical functioning, loss of independence, and lack of a purpose. Depression can also be related to many illnesses and side effect of many medications. Some symptoms include loss of appetite, insomnia, loss of interest in most usual activities, and somatic distress which makes eating unappealing.
  • Residents with dementia or late-life psychotic disorders may become paranoid and suspicious that the food being served is poisoned. When serving meals to demented residents, it is common to be confronted with refusal-like behavior such as holding their mouth shut or turning their head away.

Improvement of Nutritional Status

  • Optimal food and nutrition care can help to promote the quality of life of the elderly living in LTC . The health care professional who is best prepared to assess a person for malnutrition and to plan appropriate interventions is the registered dietitian.  A dietitian can provide nutritionally adequate, culturally appropriate food which is acceptable to residents’ needs. It is important to keep in mind the ethnic, cultural and social aspects of food. Besides seeing food as nutritional, the elderly attach religious meaning to specific ethnic foods. Thus, the LTC facility must replace or modify the menu to consider these preferences. Dietitians may provide nourishment (sandwiches, hi pro cereal, ice cream plus, milk shakes, etc) to increase residents’ caloric intake. Food preferences can be updated frequently and herb seasonings added to trays for flavor enhancement. Edentate elders may benefit from mechanically altered food.
  • It is the position of the Academy of Nutrition and Dietetics to liberalize the diet prescription for residents who suffer from poor appetite and substantial unintentional weight loss as to improve their quality of life. Thus, a liberalized approach to diet prescriptions, when appropriate, can enhance both quality of life and nutritional status.
  • When the frail elderly cannot meet their nutritional needs through meals alone, nutritional oral liquid supplements are often prescribed as an intervention. Dietary supplements provided between meals instead of with meals may be more effective in increasing energy consumption. However, in one study seniors who had low body weight status tend to compensate for the additional supplement energy consumed by reducing meal intake. Therefore, supplement use should be determined on an individual basis rather than as a routine recommendation.
  • Studies show that well staffed nursing homes reported significantly lower resident care loads on all staffing reports and provided better care. A minimum of 20-30 minutes is needed to assist adequately a dependent resident with his or her meal and to promote a quality experience for the resident. In order to improve overall care and prevent malnutrition, nursing homes need to be properly staffed.
  • Residents experiencing symptoms of depression or refuses to eat due to dementia can greatly benefit from psychological and psychiatric evaluations. Experienced nurses may also have tricks up their sleeve like knowing what to say or do to get the residents to eat. Sometimes, all that is required is to think outside the box. The recreation department can work wonders too.
  • Some nursing homes designate a CNA to go around asking residents what they would like to eat on a daily basis. One study showed that when menus are selected closer to mealtimes, there is an increased risk of malnutrition. Perhaps when menu items are selected far in advance, the person making the selections use greater care in matching menu choices with resident food preferences and when choices are made closer to mealtimes, the person choosing may not have the time to verify residents’ preferences.
  • Residents who have difficulty using plates, cups, and utensils may benefit from an Occupational Therapy evaluation where adaptive eating equipments may be recommended. For example, a resident with reduced range of motion such as severe arthritis or upper extremity weakness may benefit from built up utensils.
  • Studies show that using bulk foodservice, or cafeteria style with waitress service, can significantly increase energy intake of cognitively impaired older adults. The higher intake has been attributed to improved plate presentation, temperature, food choice at the time of service, and portion size flexibility.
  • Buffet-style dining is another foodservice system that have shown positive results in improving total energy intake of the elderly. Food is served on a steam table and allows residents to make their own food selections from a variety of food choices. Food temperatures are maintained, resulting in improved food quality. Residents may also have second helpings of their favorite foods. The dining room is enhanced with tablecloths, china, seasonal decorations and age-appropriate music.  Evening meals become a major social activity and family members can join at mealtimes.
  • The Dining with Dignity Program is a campus-community collaboration project that recognizes the nutritional needs of the elderly and the important role of food in their social and cultural lives. DDP was started to target aspects of malnutrition and dehydration amenable to social and environmental interventions by providing individual assistance during meals and creating a positive dining experience. The social support concept incorporates supportive behaviors and acts within an environment of shared empathy, trust, and respect. The four types of social support are emotional, informational, appraisal, and instrumental. Emotional support is the provision of a loving and caring relationship. Informational support is helpful advice and suggestions. Appraisal support is feedback an individual can use to self-assess. Instrumental support is direct assistance given to another person to resolve a problem or situation. These four types of support were implemented in the Dining with Dignity program and positively impact the nutritional status of the elderly.
  • Implementing a social support system with a pleasant dining room environment at a LTC center can enhance resident satisfaction with meals. One study interviewed residents who lived in the same facility but were separated into two units. One unit had an intact social environment shaped in part by a pleasant, attractive dining room with tables set for four people who could engage in conversation. The second floor unit was characterized by an unpleasant, small, crowded dining room where people were hurried fed by nursing staff. Residents of that unit chose to eat in their rooms rather than watch the feeding procedures. Residents in the socially intact unit reported satisfactory interpersonal relationships and they found the food to be adequate or good. Conversely, residents in the second floor unit reported general dissatisfaction with staff and the food despite it being the same food prepared in the same kitchen. The study concluded that elements within the social environment influenced feelings of well-being and resident enjoyment of food.

What are some other ways to improve the nutritional status of the elderly? Do you have any tricks up your sleeve to help residents with undesirable weight loss eat?

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