Malnutrition in the Long Term Care Setting

As nutrition professionals, we have a responsibility to our residents to identify, prevent and treat malnutrition.

How do we define malnutrition?

We can describe malnutrition as inadequate energy or protein over time, resulting in loss of fat and muscle stores in the body. This can occur for a variety of reasons, and can be dangerous for our elderly residents in skilled nursing / long term care settings.

What are the risk factors?

There are a variety of risk factors for malnutrition, including age, multiple medications, and poor meal intake.? The factors that are most prevalent in the long term care setting are:?

1. Chronic disease: conditions such as cancer, Parkinson's, and diabetes may alter appetite or affect weight and metabolism
2. Cognitive impairments: many of our residents struggle with cognitive difficulties such as dementia that may alter appetite and intake
3. Depression / mental health concerns: dietitians should be aware of resident depression and watch for signs and symptoms of malnutrition that may result?
4. Functional impairments:? poor swallow function or limited mobility may also affect meal intake and nutrition status

Since the purpose of skilled nursing is to recover and hopefully discharge home or to a permanent setting, dietitians need to be aware of these risks and take steps to mitigate them. Seniors whose diminished intake puts them at risk for malnutrition may experience wt loss and functional decline, which in turn increases their risk for falls and skin breakdown. It is also associated with increased hospitalizations, and even elevated risk of resident mortality.

What does malnutrition look like in the long term care setting?

As clinicians, we must constantly be on the lookout for warning signs when someone is at risk of malnutrition. For example:

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• Observing the percentage of meal intake will reveal whether a resident is meeting their estimated needs.?
• Changes in body weight are an obvious warning sign. Watch for significant losses greater than 5% at 30 days, 7.5% at 90 days, or 10% at 180 days.
• We should be assessing our residents for signs of fat loss and muscle wasting. Clinical tools such as the Nutrition Focused Physical Exam can reveal possible malnutrition. Look for physical signs such as scooping at the temples, prominent clavicles, or loss of mass of the larger muscles of the thigh or calf.
• Significant changes in a resident’s condition may signal malnutrition, such as diminished functional status, or eating or behavior changes.

So how can we help?

It is our responsibility to not only assess the resident on paper but also in person with our eyes and ears. We need to make diet and intervention decisions based on the full person, not just the list of diagnoses in their chart. Residents have a right to make informed choices and be actively involved in their care and health decisions. The best plan of care is one with which the resident agrees and is willing to participate.?

One important intervention we can apply is the liberalization of diet orders, even before adding supplements. Liberalized diets are associated with better intake of food and beverages, which minimizes malnutrition risk. For many older adults in this setting, the benefits of a liberalized diet may outweigh the risks associated with chronic disease. The chart below illustrates this point.

Restrictive diets ↘ Reduced eating pleasure ↘ Decreased intake ↘ Unintentional weight loss ↘ MALNUTRITION

Also, it is of ultimate importance that we collaborate with the other clinicians on the interdisciplinary team. Nurses and CNAs are invaluable sources of information regarding a resident’s preferences, habits, and eating behaviors and can be instrumental in identifying the early warning signs of malnutrition risk.

What is our ultimate nutrition goal?

Our priority for nutrition care in the skilled nursing / long term care setting is to maximize intake to prevent unintentional weight loss and malnutrition. Providing residents with an enjoyable eating environment, offering feeding assistance as needed, and limiting dietary restrictions will help toward this goal. By properly identifying the risks, assessing the resident with compassion and cooperation, working as part of a dynamic health care team, and implementing appropriate interventions, we can minimize the risks of malnutrition for our long term care residents.