It was November in Atlantic City, New Jersey, and the line moved slowly toward the hotel’s grand ballroom. A few of the white-haired congregants clung to walkers. Many were accompanied by middle-aged children enlisted to carry the bounty: a free Thanksgiving turkey—a reward to the casino’s regulars. One woman, slight, with a shock of hair the color of tin and a harsh bass voice that betrayed years of smoking, argued with her daughter about the car. “Just go outside and give the valet the ticket now,” the daughter urged. It was an unusually warm day for November. But her mother wanted only her turkey. She growled once they picked it up. “It’s smaller than last year’s,” she lisped through missing front teeth. Together they headed back, at long last, toward the car.
In one sense, this was an elite group of older adults. Its members were mobile and had family able to cater to them. Yet if one were to interview everyone in this crowd, a host of nutritional problems would likely emerge. Signs of poor dental care and chronic illness are evident. Further investigation might unveil a caregiver who has spent months tending to a sick spouse and at least one person who spends most mealtimes alone, staring out a window, barely picking at food.
As the body ages, physiologic and psychosocial changes set the stage for poor nutrition. In fact, even in America, where obesity is on the rise, undernutrition and malnutrition are widespread in older adults (age of 65 and older). The American Society for Parenteral and Enteral Nutrition defines malnutrition as “any disorder of nutrition status, including disorders resulting from a deficiency of nutrient intake, impaired nutrient metabolism, or over-nutrition.” 1 According to The Merck Manual of Diagnosis and Therapy (17th edition, online), it can be caused by a variety of factors:
- inadequate intake
- a loss of nutrients resulting from diarrhea, excessive perspiration, hemorrhage, or renal failure
- drug addiction
The Nutrition Screening Initiative (NSI), a multi-disciplinary coalition headed by the American Dietetic Association and the American Academy of Family Physicians, estimates that 40% to 60% of hospitalized older adults are malnourished or at risk for malnutrition; it also estimates that 40% to 85% of nursing home residents suffer from malnutrition and that 20% to 60% of home care patients are so afflicted. 2 For those responsible for the care of these patients, this is important because malnutrition is associated with longer lengths of stay in hospitals and increased costs. Furthermore, malnourished patients are more likely to have diminished muscle strength and wounds that heal poorly; they are prone to developing pressure ulcers, infections, and postoperative complications.
These estimates make one point clear: in all health care settings today, nurses must be vigilant about recognizing undernutrition and employ appropriate interventions. To that end, this article will focus on macronutrients (carbohydrates, proteins, and fats) and the physiologic and psychosocial changes that make undernutrition a real threat to older adults.
FORMS OF POOR NUTRITION
Protein-energy undernutrition is the type of undernutrition found most often in older adults. It can be caused by either a decrease in intake or the hypermetabolism associated with certain conditions (such as trauma, fever, and surgery). According to the Institute of Medicine (IOM), a diagnosis of protein-energy undernutrition requires both “clinical and biochemical evidence of insufficient intake.” 3 Physical signs include wasting, a low body mass index (BMI), and biochemical evidence such as decreased serum albumin or other serum protein levels. Marasmus and kwashiorkor are two frequently discussed kinds of protein-energy undernutrition.
Obesity, a serious public health concern in the United States and elsewhere, is a nutritional disorder commonly seen in older adults, but the danger it poses to them is uncertain. 3 In older adults, a high BMI has not been shown to predict death, and there is some evidence that excessive weight in old age serves a protective function against some injuries, such as hip fracture. Furthermore, treatment options for obesity in the elderly are not clearly defined or based on evidence. 4 The IOM maintains that the benefits and risks of weight reduction in obese older adults must be considered on a case-by-case basis. 3 An additional loss of lean body mass (body tissues not containing fat or fat-free mass), already diminished with age, may not always be appropriate in the elderly, in whom the loss of fat-free mass is associated with significant morbidity and mortality. It has been suggested that ideal body weights for older adults may actually be higher than those for younger adults. 4
INTAKE: DAILY REQUIREMENTS
As people age, physiologic changes affect the body’s need for calories, protein, and fluid. As described by the IOM, “with aging, a gradual decline in lean body mass and an increase in body fat occur. A reduction in lean body mass results in a lower basal metabolic rate, thus reducing energy needs [that is, required calories] of older persons.” 3 But illness, injury, stress, and activity level may increase a person’s total daily needs.
The following is a summary of the daily requirements for healthy older adults.
- approximately 30 kcal per kg of body weight, no more than 30% of which should be from fat 5–7
- an average of 0.8 to 1 g/kg of protein 6 (for example, a person who weighs 140 lbs. [63.6 kg] would need 51 g to 64 g of protein per day, which would be accomplished with three servings of any of the following: two 8-oz. cups of milk; 5 tablespoons of peanut butter; one chicken leg; or 3 oz. of canned tuna, hamburger, or American cheese); evidence suggests that synthesis and breakdown of protein are greater in older adults than in their younger counterparts, 8 and they therefore require more protein
- a minimum of 1,500 mL of fluid 2, 9 (certain conditions such as fever, fistulae, or draining wounds can increase the need for fluids; others such as renal or congestive heart failure will decrease it)
Dietary, economic, psychosocial, and physiologic factors place older adults at increased risk for developing undernutrition.
Older adults are at risk for poor nutrition as a result of having little or no appetite, problems with eating or swallowing, inadequate servings, fewer than two meals a day, or insufficient hot meals.
Limited income has driven some older adults to restrict the number of meals they eat each day, to eat bread and drink juice in place of more appropriate food, and to hunt for bargains while grocery shopping. 10 They may also change their shopping styles according to the time of the month; those on fixed incomes often receive funds only once a month. Fresh vegetables may be an option upon receipt of the monthly check, but by the end of that 30-day period, purchases may be limited to inexpensive nonperishables such as cold cereal.
Older adults who live alone may lose the desire to cook because of loneliness. In fact, Shahar and colleagues found that the appetites of widows often decrease, as does their enjoyment of meals; these factors put them at risk for weight loss. 11 Other older adults may have difficulty cooking for themselves because of disabilities or inexperience in the kitchen. 10 Finally, older adults (especially those in rural areas) can be at high risk for undernutrition if they lack access to transportation to stores.
Older adults are more likely to have chronic conditions that affect intake. For example, disability can hinder the ability to prepare or ingest food, and depression can cause a decrease in appetite. 2 Poor dental health (including cavities, gum disease, and missing teeth) is another risk factor, as is xerostomia, or dry mouth, which impairs the “ability to lubricate, masticate, and swallow food.” 8 Antidepressants, antihypertensives, and bronchodilators can contribute to xerostomia.
Physiologic changes that put older adults at risk for poor nutrition include a decrease in lean body mass and the redistribution of fat around internal organs. 12–16 These changes contribute to the decreased caloric requirements seen in older adults. 8 Because lean body mass contains metabolically active tissues, it burns and requires more calories. As lean body mass decreases, so does the number of calories required. In addition, shortening of the spine and alterations in skin thickness, turgor, elasticity, and compressibility can alter anthropometric measures. Finally, changes in taste—which can be caused by medications, nutrient deficiencies, or taste bud atrophy—can also alter nutritional intake.
FRAILTY: AN IMPORTANT CONSIDERATION
Not only are malnourished older adults prone to adverse health outcomes, they are also prone to frailty—which can be the start of a downward spiral. Frailty, once termed failure to thrive in older adults, is now considered a distinct syndrome, a precursor to or a cause of disability. 17, 18 A general definition of frailty is a “biological syndrome of decreased reserve and resistance to stressors, resulting from cumulative declines across multiple physiological systems, and causing vulnerability to adverse outcomes.” 17 The Cardiovascular Health Study Research Group defined frailty as a condition in which at least three of the following five symptoms are present: weakness, a slow walking speed, a low level of physical activity, unintentional weight loss, and exhaustion. 18 Malnutrition has been identified as one of the four causes of frailty. 19 Others include atherosclerosis, cognitive impairment, and sarcopenia. Frail older adults are more likely to die, be hospitalized, or become disabled. 18 Restrictive diets may be contraindicated in frail older adults who are institutionalized. 2
SCREENING AND ASSESSMENT
Because nutritional assessment is essential to preventing disease and promoting health in older adults, it should become routine when caring for this population. 2 Many components of such an assessment—determining weight, height, weight history, and functional limitations—are already standard. But a more in-depth assessment, in which status is determined by analyzing “clinical, dietary, and social history; anthropometric and biochemical data as well as drug–nutrient interactions,” is necessary. 20
The Mini Nutritional Assessment (MNA) is a two-part tool that can help nurses identify older adults at risk for or suffering from malnutrition. 21 The first part assesses food intake, mobility, and BMI and assesses for weight loss, psychological stress or acute disease, and dementia or psychological conditions. It takes about three minutes to complete. If a patient scores 11 points or less, the second half of the MNA provides a more in-depth nutritional assessment. The MNA is available through the Hartford Institute for Geriatric Nursing’s Try This series at www.hartfordign.org/resources/education/tryThis.html (click on “Assessing Nutrition in Older Adults”).
When an older adult is found to be at risk for or suffering from malnutrition, immediate consultation with an interdisciplinary health care team that includes a dietitian or nutrition support nurse, a pharmacist, and a physician is imperative.
Assessing dietary intake is important in every clinical setting. In an inpatient setting, if a patient has lost weight, is in a hypermetabolic state, or has low serum protein levels or wounds that aren’t healing properly, nurses or nursing assistants may be asked to document intake with a calorie count (also known as a nutrient intake analysis) for a specified period. 20 This is especially important if it’s unclear whether a patient’s dietary intake is adequate for his needs. In outpatients, these same concerns may prompt a request for a dietitian to provide a food-frequency or a dietary-recall questionnaire, in which a patient reports everything he has had to eat or drink over a set period (usually 24 hours).
In nursing homes that receive Medicare funding, certified nursing assistants record the percentage of food consumed by each resident at each meal. When the percentage drops below 75%, a nurse is required to perform a full assessment, including checking the resident’s records, dietary flow sheets, dietary progress notes, and assessments. In addition, the nurse should ask the patient about the reasons for his decreased intake, as well as confer with the direct care staff and dietitian regarding possible problems. However, in a comparison of estimates of food consumption completed by master’s-prepared nurse researchers and certified nursing assistants, (40 residents were followed for three meals on three consecutive days), the certified nursing assistants’ estimates of how much food each resident consumed were considerably higher than the estimates made by nurses. In fact, only 16% of nurses and certified nursing assistants agreed. 22 This is not surprising, however, because most certified nursing assistants reported having trouble remembering the percentage of food the patients ate when completing charts, and some assistants didn’t understand how to estimate percentages. These findings reinforce the fact that regular monitoring of the auxiliary staff’s charting is necessary, especially when patients or residents are nutritionally compromised.
Anthropometry employs measurements of height and weight to assess nutritional status; both measurements are used to calculate the patient’s BMI, which is used to diagnose obesity and underweight. Because of the importance of these two measurements, nurses should be cautious in delegating this responsibility to nursing assistants. If they decide to do so, interrater reliability can be established by rechecking the patient’s measurements and comparing them to the nursing assistant’s findings. This should be done on a regular basis.
In the elderly, it’s even more important to record measured height and not self-reported height; because of the shortening of the spine, self-reported height may be off by as much as 2.4 cm. 13 The recommended procedure for measuring body height in an adult is to use a measuring rod on a balance beam scale. With shoes removed, the patient stands as straight as possible and looks straight ahead. The measuring rod is lowered onto the crown of the head. In those who can’t stand or stand erect or who have spinal curvature, measurement of knee height can be used. Detailed instructions on this procedure from the Long Term Care Institute can be found at www.fiu.edu/%7Enutreldr/LTC_Institute/materials/LTC_Products.htm#7.
Both current weight and weight history are crucial components of an accurate nutritional assessment. When completing a weight history, it’s important to note the patient’s usual body weight and any history of weight loss, including whether the weight loss was intentional or unintentional and over what period it occurred. A loss of 10 lbs. over a six-month period—whether intentional or unintentional—is a red flag indicating the need for further assessment. Large-scale epidemiologic studies of older adults associate a history of weight loss with increases in morbidity and mortality rates. 3
Once accurate measurements of weight and height are obtained, BMI is calculated as follows: weight in kilograms is divided by height in meters squared. But the appropriate BMI for older adults is in dispute. According to the NSI in 2002, the recommended BMI range for an older adult is 22 to 27, with low values indicating underweight and high values indicating overweight. 2 In comparison, the National Heart, Lung, and Blood Institute recommends a BMI in the range of 18.5 to 24.9, regardless of age. 7 Nonetheless, most experts on geriatric nutrition endorse the NSI’s recommendations.
Assessing visceral proteins.
Serum measurements of visceral protein levels can help determine the size of the visceral protein pool and, therefore, whether the patient’s nutritional intake is adequate. The most frequently measured levels are those of albumin, transferrin, prealbumin, and retinol-binding protein.
The serum albumin level, which has a half-life of 21 days, is a good indicator of a patient’s nutritional status a few weeks prior to testing and can help in identifying chronic undernutrition. A serum albumin level of less than 3.5 g/dL is considered an indicator of an elevated risk of poor nutritional status, including malnutrition. 23 For example, an albumin level of 4 g/dL on June 21 would suggest that the patient’s nutritional status was relatively normal around June 1. A low albumin level is associated not only with malnutrition but also with death.
A problem with interpreting the significance of serum albumin levels is that levels are inversely related to hydration. A person who is overloaded with fluid might have a very low serum albumin level, and a person who is dehydrated might have a very high serum albumin level; neither finding would reflect true nutritional status. Albumin is also an acute phase reactant—during acute stress or injury, albumin may be suppressed as the body goes through an inflammatory response. But of all the visceral protein measurements, the test for the serum albumin level is the cheapest and the one that’s most commonly documented.
Prealbumin and retinol-binding protein levels are useful indicators of nutritional status in acute or subacute settings because of their short half-lives. 23 Prealbumin has a half-life of 72 hours, while that of retinol-binding protein is only 12 hours. Transferrin, which acts as an iron-transporting protein, has a seven-day half-life, which is significantly shorter than that of albumin. But because it’s related to iron levels, the transferrin level may not always be a sensitive indicator of nutritional status. Tests for transferrin, albumin, prealbumin, and retinol-binding protein levels have to be ordered specifically; those for prealbumin and retinol-binding protein levels are the most costly. The normal range of prealbumin is 19.5 to 35.8 mg/dL, that of retinol-binding protein is 3 to 6.5 mg/dL, and that of transferrin is 230 to 390 mg/dL. 23, 24
When does undernutrition begin? It’s unknown whether hospitalized elderly patients are admitted with preexisting protein-energy undernutrition or develop it during their hospital stays. In a study one of the authors (Rose Ann DiMaria-Ghalili) conducted of elderly patients who had undergone elective coronary artery bypass grafting, 25 albumin and transferrin levels and BMIs were within normal limits in the majority of patients before admission during preoperative testing, but 85% of patients had a 0.5 g/dL or greater drop in albumin levels five days postoperatively and 99% of patients had a drop in transferrin levels during the same period. Four to six weeks after discharge, albumin and transferrin levels had returned to normal in most patients, but BMIs had decreased in 95% of elderly patients, and the more weight patients lost, the more likely they were to be rehospitalized and report lower levels of physical health. 26
These data suggest that hospitalization of elderly patients can cause profound changes in nutritional status that can remain into the unmonitored post-discharge period. This is a concern because, according to requirements of the Joint Commission on Accreditation of Healthcare Organizations, a nutritional assessment is required only within 24 hours of a patient’s admission. When screening only takes place early during a hospital stay, clinicians may overlook worsening nutritional status in elderly patients later on. When patients are hospitalized longer than a week, nutritional reassessment needs to become part of the routine plan of care.
A referral to a dietitian should be made as soon as undernutrition is diagnosed or identified as a possibility. A pharmacist may review the patient’s medications to determine the presence of drug–nutrient interactions (many medications can cause anorexia or alter taste or appetite), and a multidisciplinary team specializing in nutrition should be consulted. The following interventions can improve the nutritional status of your patients.
Alleviate dry mouth.
Instruct patients with dry mouth to avoid caffeine; alcohol and tobacco; and dry, bulky, spicy, salty, or highly acidic foods. 8 Actions that can be taken by the patient include eating sugarless hard candy or chewing gum to stimulate saliva (not appropriate for patients with dementia or dysphagia), applying petroleum jelly to the lips and dentures, and taking frequent small mouthfuls of water.
Improve oral intake.
You can implement several strategies in the hospital setting to encourage eating at mealtimes.
- Walk around at mealtimes to determine how much food is being consumed and whether assistance is needed. 27
- Take your breaks before or after mealtimes, whenever possible, to ensure that adequate staff are available to help patients with meals.
- Encourage family members to visit at mealtimes. Ask them to bring favorite foods from home, as long as they are in keeping with the patient’s diet. Ask about the patient’s food preferences.
- Suggest small, frequent meals with adequate nutrients to help patients regain or maintain weight. Ask dietary services to provide nutritious snacks.
- Remove bedpans, urinals, and emesis basins from rooms before mealtimes.
- Administer analgesics and antiemetics on a schedule that will diminish the likelihood of pain or nausea during mealtimes.
- Serve meals to patients in a chair if they can comfortably get out of bed and remain seated.
- Create a more relaxed atmosphere by sitting at the patient’s eye level and making eye contact when feeding her. 28
- Order a late food tray or keep food warm if patients are not in their rooms during mealtimes.
- Don’t interrupt patients for rounds and non-urgent procedures during mealtimes. 5
- Help patients with mouth care and placement of dentures before food is served.
Provide specialized nutrition support.
Older adults should be started on specialized nutrition support if they can’t, shouldn’t, or won’t eat adequately and if the benefits of improved nutrition outweigh the associated risks. 1 (See Figure 2, page 46.) Among the risks of parenteral nutrition are catheter-related infection, hyperglycemia, metabolic bone disease, fluid and electrolyte disturbances, and elevations in liver enzyme levels. 29 Among the risks of enteral tube feeding are aspiration pneumonia, fluid and electrolyte imbalances, feeding intolerance, and gastrointestinal disturbances.
While older adults receiving home parenteral nutrition are routinely monitored in the home setting, there may be a gap in the delivery of professional care to older patients sent home receiving tube feedings. 30 In a recent study of older adults receiving home enteral nutrition, complications led to unscheduled health care visits and readmissions; an interdisciplinary approach to monitoring these patients in the home is clearly needed. 30
Eating is the most time-intensive activity of daily living, but trained volunteers can help set up meal trays, assist with feeding, and keep patients company during meals. It’s especially important to ensure adequate staffing at mealtimes; the failure to do so has been linked to poor care, such as spending too little time assisting people with meals (which can lead to dehydration). 31, 32 However, all volunteers should be instructed in safe methods of improving intake in patients with dementia or neuromuscular disorders (see “Feeding patients with dementia or neuromuscular disease,” page 48).
Provide oral supplements.
High-calorie, nutrient-rich supplements are a good intervention for people who are unable or unwilling to eat. The NSI states that improvements in body weight and survival have been shown in patients receiving oral supplements. 2 For example, one study of illness related to malnutrition in older adults concluded that “oral nutritional supplements have a greater role than dietary advice in the improvement of body weight and energy intake.” 33
There are a variety of supplements, including those created for patients with diabetes, chronic obstructive pulmonary disease, renal disease, and liver disease. Some of these products are enriched with fiber; supplements are also available as pudding, soups, coffee, and clear liquids. Supplements are not designed to replace meals but should be provided between meals (not within the hour preceding a meal) and at bedtime. But because Medicare will not pay for oral supplements after discharge, the cost may be prohibitive to an older person on a limited or fixed income. Instruct patients and caregivers in how to take in additional calories and protein. (See Suggestions for Increasing Protein Intake, page 48.)
The “nothing by mouth” order.
In preparation for certain diagnostic tests or procedures, patients are often instructed to take nothing by mouth after midnight. When possible, schedule older adults for these tests or procedures early in the day to decrease the length of time they are not allowed to eat and drink. If testing late in the day is inevitable, ask the physician whether the patient can have an early breakfast.
Feeding patients with dementia or neuromuscular disease.
Nurses may be the first health care professionals to realize that a patient is having difficulties eating. When this occurs, referrals are called for: a dietitian, a dentist, a speech therapist for issues concerning swallowing, and an occupational therapist for adaptive equipment such as weighted silverware or easy-grip cups. Early involvement of the interdisciplinary team can give the patient with dementia or neuromuscular disease a better chance of maintaining independence. Patients with dementia who live long enough will eventually need to be fed.
There are three ways to improve eating in people with dementia: changing the environment in which meals occur, changing the caregiver’s behavior, and changing the patient (through medications such as anticholinesterase inhibitors). 34, 35 Whether or not medications are involved, the first two methods should always be attempted.
The first step in changing the environment (especially within institutions) is to assess the area where meals are served. Research shows that several actions greatly help the patient focus on meals, including trying to create a homelike environment by preparing food close to the place where it will be served to stimulate senses; observing as many former rituals as possible (such as handwashing and saying a blessing); avoiding clutter and distractions; maintaining a pleasant, well-lighted room; and trying to keep food as close to its original form as possible.
Other suggestions include
- making sure that the patient’s glasses and hearing aid are in good working order.
- considering the need for pain medication before meals.
- providing therapeutic dinnerware and, when possible, positioning the patient in a straight-backed chair, with feet on floor and chin slightly tucked.
- focusing on the meal. Assist as needed by relying on cues from the patient, which may include turning away (may signal that the patient has had enough, or that he needs to slow down) or leaning forward and opening his mouth (which usually means the patient wants more food).
- demonstrating what you expect the patient to do. For example, if you want the patient to chew and swallow, state this desire and then mimic this action using exaggerated motions.
Feeding patients with advanced dementia.
Care-givers and providers may be inclined to initiate tube feeding as a way to offset the eating difficulties associated with advanced dementia. Commonly cited reasons for the use of tube feeding in patients with advanced dementia include preventing aspiration pneumonia, improving survival, preventing or improving pressure ulcers, offsetting infectious complications, and improving functional status and comfort level. 36, 37 However, a review of the evidence shows that there are no clear data “to support tube feeding of demented patients with eating difficulties” for any of the commonly cited reasons. 36 Hand feeding is still considered the best intervention, and tube feeding should only be started if the patient “continues to decline in some clinically meaningful way”; tube feeding in this population “seldom achieves the intended medical aims and . . . rather than prevent suffering . . . can cause it.” 37
After discharge from an acute or subacute care setting, patients must have adequate resources to maintain a healthy nutritional status. If a patient being discharged home is to maintain an oral diet, involve social services with discharge planning to ensure that the patient can buy and prepare food. In addition, refer patients to programs such as Meals on Wheels or services that provide congregate meals. Investigate the volunteer services in your community. Often, volunteers from local community groups, such as churches or high schools, can be enlisted to help shop, prepare meals, or even share meals with older adults living alone. Nurses can become an integral part of such a volunteer force; a great community service project for nursing students would be to develop community services that deliver meals to older adults living at home.
Complete the CE test for this article by using the mail-in form available in this issue, or visit NursingCenter.com’s “CE Connection” to take the test and find other CE activities and “My CE Planner.”
TIPS FOR NURSES: BETTER NUTRITION IN OLDER ADULTS
- Frequently reassess the patient’s nutritional status so proper nutritional interventions can be administered in a timely fashion.
- Keep track of how much a patient is actually eating. Consider using supplements.
- Provide information to elderly caregivers on how to maintain their own nutritional health.
- Keep yourself and nursing assistants up to date on Nutrition Care Alerts (found at www.cdhcf.org/nsi/NCA%20Nursing%20Facilities.pdf).
- When appropriate, encourage family members to assist with meals.
- Oral supplements should be served between meals. Supplements should not replace meals and should not be served within the hour preceding a meal.
- Obtain a careful weight history and carefully measure weight and height at each visit. Height could decrease over time in the older adult.
- When appropriate, provide instructions on how to increase calories and protein intake.
- Refer to community agencies if there are limitations to shopping or preparing foods.
- Refer to community agencies if there are limitations to shopping or preparing foods.
- Provide instructions on how to increase calories and protein intake.
- Monitor trends in weight. Alert primary care provider if patient is losing weight so interventions can be instituted.
NUTRITION SUPPORT NURSING
An evolving specialty.
The role of the nutrition support nurse has evolved over the last four decades. Early professionals in this field were primarily assigned to provide care for patients receiving total parenteral nutrition, including IV site care and maintenance, patient monitoring, and interdisciplinary education. Many worked as part of multidisciplinary nutrition support teams, which were popular in U.S. hospitals before the early 1990s. But many of these teams (and the nutrition support nursing jobs they created) disappeared as a result of financial constraints and downsizing. Currently, the major practice areas for nutrition support nurses include clinical practice, academia and research, and entrepreneurial ventures. It is expected that in the 21st century, practice areas will focus on obesity management and the elderly. For information on becoming certified as a nutritional support nurse, go to www.ptcny.com/clients/NBNSC.
Guenter P, et al. JPEN J Parenter Enteral Nutr 2004;28(1):54–9.
‘A New Look at the Old’ Online
A series of Webcasts designed to improve multidisciplinary care.
Further explore the topics presented in the series “A New Look at the Old” by going online; over the course of the series 15 free Webcasts will run, created through a collaboration of AJN, the Gerontological Society of America, and PRIMEDIA Healthcare, and sponsored in part through a grant from Atlantic Philanthropies. The first, “The Challenge to Come: The Care of Older Adults,” premiered on January 18. The second, “Presentation of Illness in Older Adults,” was available as of February 21. For information about the schedule or to view an archive of previous Webcasts, go to www.nursingcenter.com/AJNolderadults. This Web page includes a forum for comments and questions about the Webcasts or articles in this series.
Suggestions for Increasing Protein Intake
- Add chopped, hard-cooked eggs to salads, dressings, vegetables, casseroles, and creamed meats.
- Add extra eggs or egg whites to quiches and to pancake and French toast batter.
- Add extra egg whites to scrambled eggs and omelets.
- Use in beverages and in cooking when possible.
- Use in preparing hot cereal, soup, cocoa, and pudding.
- Add cream sauces to vegetables and other dishes.
- Add to regular milk and milk drinks such as milk shakes.
- Use in sauces, cream soups, casseroles, meat loaf, mashed potatoes, breads, muffins, puddings, and custards.
Ice Cream, Yogurt, Frozen Yogurt
- Add to cereals, fruits, gelatin desserts, and pies; blend or whip with soft or cooked fruit.
- Add to milk.
Hard or Semisoft Cheeses
- Melt on sandwiches, breads, muffins, tortillas, vegetables, eggs, or desserts such as stewed fruit or pie.
- Grate and add to soups, sauces, casseroles, meat loaf, rice, noodles, or mashed potatoes.
Cottage Cheese or Ricotta
- Mix with or use to stuff fruits and vegetables.
- Add to casseroles.
- Stuff pasta such as manicotti or shells.
Meat and Fish
- Add chopped, cooked meat or fish to vegetables, salads, casseroles, and soups.
- Use in omelets, soufflés, quiches, sandwich fillings, and stuffings.
Beans or Legumes
- Cook and use dried peas, legumes, beans, and bean curd (tofu) in soups or ethnic and regional dishes. Add to casseroles, pastas, and grain dishes that also contain cheese or meat.
- Spread on sandwiches, toast, muffins, pancakes, waffles, or crackers.
- Use as dip for raw vegetables such as carrots, cauliflower, and celery.
- Spread on fresh fruits such as apples and bananas.
Nuts, Seeds, Wheat Germ, and Other Ideas
- Add to casseroles, breads, muffins, pancakes, waffles, and cookies.
- Sprinkle on fruit, cereal, ice cream, yogurt, vegetables, and salads.
- Blend herbs and cream with parsley, spinach, or basil for a pasta or vegetable sauce.
Reprinted with permission from Bartlett S, et al. Geriatric nutrition handbook. New York: Chapman and Hall; 1998.
Center for Medicare and Medicaid Nursing Campaign on Nutrition and Hydration www.medicare.gov/Nursing/Campaigns/NutriCareAlerts.asp
Council for Nutritional Clinical Strategies in Long-Term Care www.ltcnutrition.org
The Role of Nutrition in Maintaining Health in the Nation’s Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population (National Academies Press, 2000) http://books.nap.edu/books/0309068460/html/R1.html#pagetop
American Dietetic Association www.eatright.org/Public/NutritionInformation/92_nsi.cfm
MedlinePlus: Nutrition for Seniors www.nlm.nih.gov/medlineplus/nutritionforseniors.html
Guidelines for the Use of Parenteral and Enteral Nutrition in Adult and Pediatric Patients (ASPEN Board of Directors and the Clinical Guidelines Task Force, 2002)
1. Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. JPEN J Parenter Enteral Nutr
2. Nutrition Screening Initiative. Nutrition statement of principle.
3. Institute of Medicine. The role of nutrition in maintaining health in the nation’s elderly: evaluating coverage of nutrition services for the Medicare population.
Washington, DC: National Academies Press; 2000.
4. Kennedy RL, et al. Obesity in the elderly: who should we be treating, and why, and how?Curr Opin Clin Nutr Metab Care
5. Allison S. Institutional feeding of the elderly. Curr Opin Clin Nutr Metab Care
6. Nutrition Screening Initiative. Nutrition intervention manual for professionals caring for older Americans.
Washington, DC: Greer, Margolis, Mitchell, Grunwald and Associates; 1992.
7. National Heart, Lung, and Blood Institute. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: the evidence report.
8. Schlenker E. Nutrition in aging.
2nd ed. St. Louis: Mosby; 1993.
9. Bartlett S, et al. Geriatric nutrition handbook.
New York: Chapman and Hall; 1998.
10. Souter S, Keller C. Food choice in the rural dwelling older adult. Southern Online Journal of Nursing Research
11. Shahar D, et al. The effect of widowhood on weight change, dietary intake, and eating behavior in the elderly population. J Aging Health
12. Lehmann AB. Review: undernutrition in elderly people. Age Ageing
13. Lipschitz DA, Mitchell CO. The correctability of the nutritional, immune, and hematopoietic manifestations of protein calorie malnutrition in the elderly. J Am Coll Nutr
14. Rudman D, Feller AG. Protein-calorie undernutrition in the nursing home. J Am Geriatr Soc
15. Bowman BB, Rosenberg IH. Assessment of the nutritional status of the elderly. Am J Clin Nutr
16. Chandra RK. The relation between immunology, nutrition, and disease in elderly people. Age Ageing
17. Fried LP, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci
18. Newman AB, et al. Associations of subclinical cardiovascular disease with frailty. J Gerontol A Biol Sci Med Sci
19. Morley JE, et al. Editorial: something about frailty. J Gerontol A Biol Sci Med Sci
20. DeHoog S. The assessment of nutritional status. In: Mahan L, Escott-Stump S, editors. Krause’s food, nutrition, and diet therapy.
9th ed. Philadelphia: W. B. Saunders; 1996. p. 361–86.
21. Rubenstein LZ, et al. Screening for undernutrition in geriatric practice: developing the Short-Form Mini-Nutritional Assessment (MNA-SF). J Gerontol A Biol Sci Med Sci
22. Kayser-Jones J, et al. Reliability of percentage figures used to record the dietary intake of nursing home residents. Nursing Home Medicine
23. Omran ML, Morley JE. Assessment of protein energy malnutrition in older persons, part II: laboratory evaluation. Nutrition
24. Kratz A, et al. Laboratory reference values. N Engl J Med
25. DiMaria-Ghalili RA. Changes in nutritional status and postoperative outcomes in elderly CABG patients. Biol Res Nurs
26. DiMaria-Ghalili RA. Changes in body mass index and late postoperative outcomes in elderly coronary bypass grafting patients: a follow-up study. Biol Res Nurs
27. Crogan NL, et al. Barriers to nutrition care for nursing home residents. J Gerontol Nurs
28. Holzapfel SK, et al. Feeder position and food and fluid consumed by nursing home residents. J Gerontol Nurs
29. Worthington P. Practical aspects of nutritional support: an advanced practice guide.
Philadelphia: Saunders; 2004.
30. Silver HJ, et al. Older adults receiving home enteral nutrition: enteral regimen, provider involvement, and health care outcomes. JPEN J Parenter Enteral Nutr
31. Kayser-Jones J. Inadequate staffing at mealtime. Implications for nursing and health policy. J Gerontol Nurs
32. Kayser-Jones J, et al. Factors contributing to dehydration in nursing homes: inadequate staffing and lack of professional supervision. J Am Geriatr Soc
33. Baldwin C, et al. Dietary advice for illness-related malnutrition in adults. Cochrane Database Syst Rev
34. Amella E. Mealtime difficulties. In: Mezey M, et al., editors. Geriatric nursing protocols for best practice.
2nd ed. New York: Springer; 2004. p. 66–82.
35. Lebert F, et al. Frontotemporal dementia: a randomised, controlled trial with trazodone. Dement Geriatr Cogn Disord
36. Finucane TE, et al. Tube feeding in patients with advanced dementia: a review of the evidence. JAMA
37. Gillick MR. Rethinking the role of tube feeding in patients with advanced dementia. N Engl J Med