Vol. 6 Issue 16
The Learning Scope
Nutrition & Hydration
Strategies for managing status of residents in long-term care.
This offering expires in 2 years: August 16, 2006
The goal of this CE offering is to provide nurses with information about nutrition and hydration of residents in long-term care they can apply to practice. After reading this article, you should be able to:
1. Describe the underlying problems that contribute to undernutrition and dehydration.
2. Discuss treatment plans that have proved to be successful.
3. Monitor outcomes to measure success.
You can earn 1 contact hour of continuing education credit in three ways: 1) For im.mediate results and certificate, go to www.advanceweb.com. Grade and certificate are available immediately after taking the online test. 2) Send this answer sheet (or a photocopy) along with the $8 fee (check or credit card) to ADVANCE for Nurses, Learning Scope, 2900 Horizon Dr., King of Prussia, PA 19406. Make checks payable to Merion Publications Learning Scope (any checks returned for non-sufficient funds will be assessed a $25 service fee). 3) Fax the answer sheet (available with credit card payment only) to 610-278-1426. If faxing or mailing, allow 45 days to receive certificate or notice of failure. A certificate of credit will be awarded to participants who achieve a passing grade of 70 percent or better.
Merion Publications Inc. is an approved provider of continuing nursing education by the Pennsylvania State Nurses Association (No. 011-3-H-04), an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation. Merion Publications Inc. also is an approved provider in California (No. 13230) and Florida (No. 3298).
Eating when you are hungry and drinking when you are thirsty are both instinctive and learned behaviors. As infants, crying gets us liquid nutrition. As children, irritability gets us fed. As able-bodied adults, nutrition and hydration often revolve around social norms, but also are a response to recognizing bodily needs.
However, when the older adult enters a long-term care facility, the power to control mealtime, meal choice and even manage thirst is to a great degree given over to healthcare providers. Thus, nursing staff must take seriously the responsibility to help residents maintain their nutritional and hydration status.
Nursing staff are directed to consult dietitians, plan nursing care and provide support and guidance for nursing assistants so that nutrition and hydration needs are managed. This article examines the underlying problems that contribute to undernutrition and dehydration, presents treatment plans that have proved to be successful and presents strategies for measuring this success in long-term care.
All adults are at risk for undernutrition and dehydration; however, the situation of residents of long-term care facilities is more complex due to the effects of chronic illness, changes associated with aging and medication usage. The Institute of Medicine has estimated that 87 percent of Medicare beneficiaries over age 65 have diabetes, hypertension and/or dyslipidemia. Other individuals have heart failure, chronic renal insufficiency or undernutrition.1
Malnutrition includes both inadequate nutrition (lack of adequate calories, protein and vitamins) and excessive intake of nutrients (elevated cholesterol or obesity).1 While excessive intake is possible due to decreased activity and a concern over residents not eating at least 75 percent of portions served, undernutrition is often a greater concern in long-term care. This can be defined as:
• weight-height ratio <90 percent of normal;
• .mid-arm muscle circumference <90
percent of normal;
• albumin <3.5 g/dL; or
• transferrin <200 mg/dL.
With aging, there is a 70 percent decrease in the number of taste buds and a 30 percent loss of muscle mass. Meanwhile, body fat increases, creating a less dense body. This results in a need to increase intake of protein, calcium and vitamin D. The body becomes less thirsty and a dry mouth becomes a common and therefore not uncomfortable feeling.
Hydration status is best described as the sum of the intracellular and extracellular compartments, which equals total body water. In the average adult male, this is approximately 42 L or 55-60 percent of total body weight. With aging, total body water decreases by approximately 6 percent in men and 8 percent in women. This normal reduction of total body water represents 9 pounds less water (in a 150-pound male) and places the older adult at much greater risk for water deficits.2 The kidneys can lose as much as 50 percent of the millions of nephrons due to aging and wear and tear from pharmacokinetics and injury, reducing the body's ability to maintain hydration homeostasis.
Hypovolemia or isotonic dehydration usually is caused by hemorrhage, GI losses or third spacing, and is manifested as acute weight loss. Clinical characteristics are somnolence and confusion. Hypertonic dehydration results from a defect in urinary concentrating ability and insufficient administration of free water. It can result from diabetes insipidus, hyperglycemia, hyperosmolar tube feedings or severe diarrhea. Other causes include undernutrition and lack of fluid intake.
Causes of Dehydration, Appetite Decrease
Medications such as anticholinergics and psychotropics can cause dry mouth, and diuretics given without adequate fluid can dehydrate. Other medications such as digoxin and fluoxetine can decrease the appetite. Diets low in sodium to control blood pressure can seem tasteless and also decrease appetite. Cognitive changes with dementia or Alzheimer's can lend to lack of interest in meal times or lack of recognition of favorite foods. Anorexia also can be caused by bereavement, confusion, depression or simply by dry mouth, which decreases the ability to taste.
Additionally, many older adults suffer from poor dentition or ill-fitting dentures, current or previous bad oral hygiene, and an inability to feed themselves. Finally, the slower emptying of the stomach and changes in digestive enzymes can trigger a feeling of satiety before the plate has been emptied.
Residents of long-term care facilities should be evaluated by a dietitian to determine whether potentially reversible causes of undernutrition can be addressed. Areas to be assessed include:
• food security (is the resident's food really being served and offered?);
• food-related functional status;
• appetite and dietary intake;
• swallowing ability;
• medications that decrease appetite;
• cognitive impairment; and
• disease-related dietary restrictions.
The Hartford Institute for Geriatric Nursing offers two assessment tools in its "Try This: Best Practices in Care for Older Adults Series." The Nutrition and Hydration Assessment and the Geriatric Oral Health Assessment Index can both serve as guides for baseline measures and monitoring of residents.3
Knowledge of modifications made to the food pyramid for older adults is equally important to success with this population. This narrower pyramid includes such modifications as no potatoes but an emphasis on whole grains and fiber. Another notable modification is eating bright-colored vegetables (green leafy) and deep-colored fruits (berries). Plenty of low- and nonfat dairy products, along with calcium, vitamin D, and B12 supplements, are recommended. This pyramid can be seen at http://www.nutrition.tufts.edu/magazine/1999fall/pyramid.html.4
At the base of the food pyramid for older adults sit eight or more servings of water/liquids daily; these include soups and juices.
Many long-term care facilities have successfully implemented hydration rounds, a scheduled opportunity for volunteers or dietary aides to offer liquids to each resident. These hydration rounds, made between meals and exclusive of medication administration, provide at least two 8 oz. servings of liquids, often something tart or tangy like lemonade or cranapple juice. The key to successful hydration rounds is to offer the liquid and assist the resident with drinking, or remain with the resident to encourage finishing the entire cup.
Medication passes in many facilities are now accompanied by 8 oz. cups of water or juice, not only encouraging increased fluid intake the 2-4 times a day residents take medications, but also helping to ensure the medications are properly dissolved for absorption.
A study conducted in a Midwestern long-term care facility found the use of a beverage cart increased fluid in each body compartment, decreased the need for laxatives, increased the number of bowel movements and decreased the number of falls among the hydrated residents.5
Assisting with feeding of a resident requires attention to the personal habits of the individual. Pacing is important to maintain interest in the meal. Varying each spoonful can offer a range of nutrients, prevent monotony and stimulate eating with various textures. Conversation and other distractions are important to maintain the social nature of meal time.
It is important to consider acceptable table manners for the older adult. The person assisting with feeding should be focused on the resident being fed, avoiding side conversations. If feeding two residents, then it should seem more like a family event. A napkin should be used for wiping drips, rather than the edge of the bib or towel. The environment should be pleasant with appropriate table settings to make the meal seem like a more enjoyable experience. Flower arrangements nearby can create a more formal mealtime environment. While the television may be turned off, watching an aquarium can promote stimulation. Bringing as many residents to the common dining area as possible also can encourage eating since it becomes a group activity. If any resident refuses even as few as three meals, a dietitian should be consulted for immediate attention to prevent malnutrition.
Any resident who experiences difficulty in swallowing should have an evaluation, first by a dietitian and then by a speech therapist. Swallowing studies can be conducted at the bedside before further diagnostic studies such as barium swallows are considered.
Use of thickened liquids, with honey or nectar consistency, has been found to be quite effective in improving swallowing. Thickening agents also can be added to liquids such as coffee, making these favorites enjoyable. The nurse should watch for pocketing of chewed foods as a clue to swallowing difficulties.
Many supplements are now available as high-calorie, high-protein snacks, often providing as much as 240 kcals in 4-8 oz. These are not intended to be substitutes for meals, yet they can be a primary source of nutrition. The intent is for these supplements to be eaten between meals to help maintain nutritional status; however, it may take encouragement from nursing personnel for these to be consumed.
Lifelong eating habits, developed from tradition, ethnicity, religion and geographic location, influence the intake of older adults. Residents who have skipped breakfast all their lives are not likely to begin eating breakfast now, just because the facility insists. (Think about your current eating patterns and how those would be supported if you relied on a facility for your meal preparation and distribution.)
Residents may not be hungry for lunch, which can be served in less than 4 hours after breakfast. Three large meals a day may be refused, but one nutritious breakfast followed by two to four snacks may be just right.
Skin turgor is not always a reliable indicator of hydration status because the skin loses elasticity during aging. However, checking skin turgor at the inner thigh may be helpful, provided the nurse is familiar with the turgor of that particular patient. Dry mucous membranes also are a good indicator of hydration status.
Monitoring urine color is one strategy for checking hydration status. When using a bedpan or other urine collection device, the color and odor of the urine can be detected. A study done by the VA system demonstrated that the color chart correlates well with urine specific gravity and osmolality, and is a low-cost way to monitor dehydration.6 Another study showed lower urine leukocyte counts and higher extracellular fluid volume are associated with providing adequate fluid to residents.7 Maintaining a regular bowel pattern also is an indicator of hydration status. Intake of water and fiber play equally important roles in preventing constipation.
Since intake and output charts tend to be unreliable, monitoring weight weekly is easier using bed and chair scales. While intake of 3,500 kcal yields approximately 1 lb., more importantly, 500 mL of fluid is about 1 lb. Thus a weight loss of 3 lbs. in one week could be attributable to a fluid deficit of 1,500 mL rather than a decrease in food intake of 10,500 kcal. Weekly weights should be recorded using the same scale at the same time of day, and this may require working with other staff to be sure consistency is maintained.
The Centers for Medicare and Medicaid Services require a Minimum Data Set (MDS) on all long-term care residents. This periodic nursing assessment examines a number of areas. One component is documentation that the resident ingests at least 75 percent of the food provided. Failure to achieve this standard triggers the assessment protocol for malnutrition in the resident. Other triggers include complaints about the taste of many foods, regular or repeated complaints of hunger, and leaving 25 percent or more of the food uneaten at most meals.
A notation should be made following every meal for every resident indicating what percent of the food provided was eaten. Monitoring the patient's weight and adjusting portion size then become critical to ensuring the resident is ingesting sufficient food. Adjusting food portions to the dietary needs of the resident is a better approach than continuing to over-feed the resident to avoid the trigger of leaving too much food on the plate.
Even with appropriate attention to nutrition and hydration, the body will eventually lose its need for food and water. Whereas we once thought it was painful for a patient to starve to death, we now know metabolism changes and the desire and need for food fades.
Terminal dehydration is not painful either, except possibly for the dry mouth that can be managed with attentive oral hygiene. Families and healthcare providers should discuss how to manage these scenarios specifically. Placing a feeding tube at this juncture may prove to be more problematic than helpful.8
Attention to nutrition and hydration needs of older adults is important for long-term care providers, hospital counterparts and family members. Consult with the dietitian and the treatment team to develop the most effective plan to support optimum nutrition and hydration. It is our responsibility to give as much attention to residents' nutrition and hydration as we give to our own physiologic needs.
1. Committee on Nutrition Services for Medicare Beneficiaries, Institute of Medicine. (2000). The role of nutrition in maintaining health in the nation's elderly. Washington DC: The National Academy Press.
2. Suhayda, R., & Walton, J.C. (2002). Preventing and managing dehydration. Medsurg Nursing, 11(6), 267-272.
3. Hartford Institute for Geriatric Nursing. (2004). Try this series. Retrieved Feb. 24, 2004 from the World Wide Web: http://www.hartfordign.org/resources/education/tryThis.html
4. Amersbach, G. (1999). More water, more fiber, fewer calories: Reinventing the food pyramid for older adults. Retrieved Feb. 24, 2004 from the World Wide Web: http://www.nutrition.tufts.edu/magazine/1999fall/pyramid.html
5. Robinson, S.B., & Rosher, R.B. (2002). Can a beverage cart help improve hydration? Geriatric Nursing, 23(4), 208-211.
6. Wakefield, B., et al. (2002). Monitoring hydration status in elderly veterans. Western Journal of Nursing Research, 24(2), 132-142.
7. Culp, K., Mentes, J., & Wakefield, B. (2003) Hydration and acute confusion in long-term care residents. Western Journal of Nursing Research, 25(3), 251-273.
8. Miller, E. (2004). Nutrition. In J. Panke & P. Coyne (Eds.), Conversations in palliative care. Pensacola, FL: Pohl Publishing.
Julia W. Aucoin is assistant professor in nursing at the University of North Carolina at Greensboro and a professional nursing development consultant.