• Preventing aspiration in older adults with dysphagia:
http://consultgerirn.org/uploads/File/trythis/try_this_20.pdf
• Assessing nutrition in older adults:
http://consultgerirn.org/topics/nutrition_in_the_elderly/want_to_know_more
• Nursing Standard of Practice: Nutrition in Aging: DiMaria-Ghalili R: Nutrition. In Boltz M, Capezuti E, Fulmer T, et al:
Evidence-based geriatric nursing protocols for best practice,New York, 2012, Springer.
• Eating and feeding issues in older adults with dementia. Part I and Part II—see eating and feeding issues:
http://consultgerirn.org/resources/#issues_on_dementia
• Nursing Standard of Practice Protocol: Providing Oral Health Care to Older Adults:
http://consultgerirn.org/topics/oral_healthcare_in_aging/want_to_know_more
• Nursing Standard of Practice Protocol: Oral Hydration Management:
http://consultgerirn.org/topics/hydration_management/want_to_know_more
• Dehydration Risk Assessment Checklist:
http://rgp.toronto.on.ca/torontobestpractice/Dehydrationriskappraisalchecklist.pdf
• O’Connor L: Oral health care. In Boltz M, Capezuti E, Fulmer T, Zwicker D: Evidence-based geriatric nursing protocols for best practice, New York, Springer, 2012.
Interview
The interview provides background information and clues to the nutritional state and actual and potential problems of the older adult. Questions about the individual’s state of health, social activities, normal patterns, and changes that guidelines for nutritional assessment of older adults can be found in the Evidence-Based Practice box.
Last name: First name:
Sex:
Screening
Complete the screen by filling in the boxes with the appropriate numbers. Total the numbers for the final screening score.
Age: Weight, kg: Height, cm: Date:
F1 Body Mass Index (BMI) (weight in kg) / (height in m2) E Neuropsychological problems
D Has suffered psychological stress or acute disease in the past 3 months?
C Mobility
B Weight loss during the last 3 months
A Has food intake declined over the past 3 months due to loss of appetite, digestive problems, chewing or swallowing difficulties?
0 = BMI less than 19 1 = BMI 19 to less than 21 2 = BMI 21 to less than 23 3 = BMI 23 or greater
0 = severe dementia or depression 1 = mild dementia
2 = no psychological problems
0 = yes 2 = no
0 = bed or chair bound
1 = able to get out of bed / chair but does not go out 2 = goes out
0 = weight loss greater than 3 kg (6.6 lbs) 1 = does not know
2 = weight loss between 1 and 3 kg (2.2 and 6.6 lbs) 3 = no weight loss
0 = severe decrease in food intake 1 = moderate decrease in food intake 2 = no decrease in food intake
IF BMI IS NOT AVAILABLE, REPLACE QUESTION F1 WITH QUESTION F2.
DO NOT ANSWER QUESTION F2 IF QUESTION F1 IS ALREADY COMPLETED.
F2 Calf circumference (CC) in cm
For more information: www.mna-elderly.com
Screening score (max. 14 points) 0 = CC less than 31
3 = CC 31 or greater
12-14 points: Normal nutritional status 8-11 points: At risk of malnutrition 0-7 points: Malnourished
FIGURE 9-4 Mini Nutritional Assessment. (Copyright Nestlé, 1994, Revision 2009, Glendale, Calif.)
have occurred should be asked. The nurse must explore the individual’s needs, the manner in which food is obtained, and the client’s ability to prepare food.
Information concerning the relationship of food to daily events will provide clues to the meaning and significance of food to that person. The older person who eats alone is con- sidered a candidate for malnutrition. Information about oc- cupation and daily activities will suggest the degree of energy expenditure and caloric intake most appropriate for the over- all activity. One’s economic status will have a direct bearing on nutrition. It is therefore important to explore the client’s financial resources to establish the income available for food.
Medications being taken should be included in the nutri- tion history. Additional medical information should include the presence or absence of mouth pain or discomfort, visual difficulty, bowel and bladder function, and history of illness.
Depression is a major cause of weight loss, so an evaluation for depression should be obtained (see Chapter 22).
Diet Histories
Frequently a 24-hour diet recall can provide an estimate of nutritional adequacy. When the older person cannot supply all of the information requested, it may be possible to obtain data from a family member or another source. There will be times, however, when information will not be as complete as one would like, or the older person, too proud to admit that he or she is not eating, will furnish erroneous information.
Even so, the nurse will be able to obtain additional data from the other three areas of the nutritional assessment.
Keeping a dietary record for 3 days is another assessment tool. What one ate, when food was eaten, and the amounts eaten must be carefully recorded. Computer analysis of the dietary records provides information on energy and vitamin and mineral intake. Printouts can provide the older person and the health care provider with a visual graph of the in- take. Accurate completion of 3-day dietary records in hospi- tals and nursing homes can be problematic, and intake may be either underestimated or overestimated. Standardized observational protocols should be developed to ensure ac- curacy of oral intake documentation as well as the adequacy and quality of feeding assistance during mealtimes. Nurses should ensure that direct caregivers are educated on the proper observation and documentation of intake and should closely monitor performance in this area.
Physical Examination
The physical examination furnishes clinically observable evidence of the existing state of nutrition. Data such as height and weight; vital signs; condition of the tongue, lips,
and gums; skin turgor, texture, and color; and functional ability are assessed, and the overall general appearance is scrutinized for evidence of wasting. Height should always be measured and never estimated or given by self-report. If the person cannot stand, an alternative way of measuring standing height is knee-height using knee-height calipers.
BMI should be calculated to determine if weight for height is within the normal range of 22 to 27. A BMI below 22 is a sign of undernutrition (DiMaria-Ghalili, 2012).
A detailed weight history should be obtained along with current weight. Weight loss is a key indicator of mal- nutrition, even in overweight older adults. History should include a history of weight loss, whether the weight loss was intentional or unintentional, and during what period it occurred. A history of anorexia is also important, and many older people, especially women, have limited their weight throughout life. Debate continues in the quest to determine the appropriate weight charts for an older adult.
Although weight alone does not indicate the adequacy of diet, unplanned fluctuations in weight are significant and should be evaluated.
Procedures for weighing people in institutions should be established and followed consistently to obtain an ac- curate picture of weight changes. Weighing procedure should be supervised by licensed personnel, and changes should be reported immediately to the provider. One might meet correct weight values for height, but weight changes may be the result of fluid retention, edema, or ascites and merit investigation. An unintentional weight loss of more than 5% of body weight in 1 month, more than 7.5% in 3 months, or more than 10% in 6 months is considered a significant indicator of poor nutrition, as well as an MDS trigger indicating the need for further assessment.
Anthropometrical Measurements
Anthropometrical measurements include height, weight, midarm circumference, and triceps skinfold thickness. These are obtained by simple body measurement procedures, which take less than 5 minutes to perform. These measure- ments offer information about the status of the older per- son’s muscle mass and body fat in relation to height and weight. Muscle mass measurements are obtained by mea- suring the arm circumference of the nondominant upper arm. The arm hangs freely at the side, and a measuring tape is placed around the midpoint of the upper arm, between the acromion of the scapula and the olecranon of the ulna.
The centimeter circumference is recorded and compared with standard values.
Body fat and lean muscle mass are assessed by measur- ing specific skinfolds with Lange or Harpenden calipers.
Two areas are accessible for measurement. One area is the midpoint of the upper arm, the triceps area, which is also used to obtain arm circumference. The nondominant arm is again used. The nurse lifts the skin with the thumb and forefinger so that it parallels the humerus. The calipers are placed around the skinfold, 1 cm below where the fingers are grasping the skin. Two readings are averaged to the nearest half centimeter. If there is a neuropathological condition or hemiplegia following a stroke, the unaffected arm should be used for obtaining measurements.
Biochemical Examination
The final step in a nutritional assessment is the biochemi- cal examination. A complete blood count, total lympho- cyte count, thyroid level, comprehensive metabolic panel, and liver function tests help assess the presence of diseases known to affect weight loss or cause loss of appetite.
Urinalysis to rule out infection, as well as a stool sample for fecal occult blood, should be included. Suggested biochemical parameters include serum albumin, choles- terol, hemoglobin, and serum transferrin. Although these parameters may also be abnormal in several conditions unassociated with malnutrition, they are useful as guides to interventions (Thomas, 2000). Serum proteins also decrease in an inflammatory reaction, infection, or liver disorder. In acute illness, hypoalbuminemia may occur but not be indicative of malnutrition; however, low serum protein levels need further investigation (Duffy, 2010).
Serum albumin of more than 4 g/dL is desired; less than 3.5 g/dL is an indicator of poor nutritional state. Prealbu- min level may be a better indicator of protein loss because it changes rapidly in the presence of malnutrition. Labora- tory test results, although not definitive for malnutrition, provide important clues to nutritional status but should be evaluated in relation to the person’s overall health status.
Unintentional weight loss remains the most important indicator of a potential nutritional deficit (Ahmed &
Haboubi, 2010).
Interventions
Interventions are formulated around the identified con- cerns. Nursing interventions are centered on techniques to increase food intake and to enhance and manage the environment to promote increased food intake (DiMaria-Ghalili, 2012). Collaboration with the inter- professional team is important in planning interventions.
For the community-dwelling elder, nutrition education and problem solving with the elder and family members on how to best resolve the potential or actual nutritional
deficit is important. Causes of poor nutrition are com- plex, and all of the factors emphasized in this chapter are important to assess when planning individualized inter- ventions to ensure adequate nutrition for older people.
Pharmacological Therapy
Drugs that stimulate appetite (orexigenic drugs) can be considered to reverse resistant anorexia but only after all other interventions have been tried. They must be moni- tored closely for side effects and have had little evaluation in frail older people. Benefits are restricted to small weight gains without indication of decreased morbidity or mortal- ity or improved quality of life or functional ability (Vitale et al., 2009).
Patient Education
Education should be provided to older adults on nutri- tional requirements for health, special diet modifications for chronic illness management, the effect of age-associated changes and medication on nutrition, and community resources to assist in maintaining adequate nutrition.
Medicare covers nutrition therapy for select diseases, such as diabetes and kidney disease, which creates un- precedented opportunities for older Americans to access information.
Special Considerations in Nutrition for Older People: Hydration,
Dysphagia, Oral Care
Several conditions warrant further discussion because they are frequently encountered in care of older adults and are related to adequate diet and nutritional status. These include dehydration, dysphagia, and oral health.
Hydration Management
Hydration management is the promotion of an adequate fluid balance, which prevents complications resulting from abnormal or undesirable fluid levels. Daily needs for water can usually be met by functionally independent older adults through intake of fluids with meals and social drinks. However, a significant number of older adults (up to 85% of those 85 years of age and over) drink less than 1 liter of fluid per day. Older adults, with the exception of those requiring fluid restrictions, should consume at least 1500 mL of fluid per day (Mentes, 2006).
Maintenance of fluid balance (fluid intake equals fluid output) is essential to health, regardless of a person’s age
(Mentes, 2006). Age-related changes, medication use, functional impairments, and comorbid medical and emo- tional illnesses place some older adults at risk for changes in fluid balance, especially dehydration (Mentes, 2008).
See the Evidence-Based Practice box for a hydration management guideline.
Dehydration
Dehydration is defined clinically as “a complex condition resulting in a reduction in total body water. In older people, dehydration most often develops as a result of disease, age- related changes, and/or the effects of medication and NOT primarily due to lack of access to water” (Thomas et al., 2008, p. 293). Dehydration is considered a geriatric syndrome that is frequently associated with common diseases (e.g., diabetes, respiratory illness, heart failure) and declining stages of the frail elderly (Crecelius, 2008). It is often an unappreciated comorbid condition that exacerbates an underlying condition such as a urinary tract infection, respiratory infection, or worsening depression (Thomas et al., 2008).
Dehydration is a problem prevalent among older adults in all settings. Dehydration is a significant risk factor for delirium, thromboembolic complications, infections, kidney stones, constipation, obstipation, falls, medication toxicity, renal failure, seizure, electrolyte imbalance, hyperthermia, and delayed wound healing. If not treated adequately, mortality from dehydration can be as high as 50% (Faes et al., 2007).
Thomas and colleagues (2008) comment that there are few diagnoses that generate as much concern about causes and consequences as does dehydration. Due to a lack of understanding of the pathogenesis and consequences of dehydration in older adults, the condition is often attrib- uted to poor care by nursing home staff and/or physicians.
However, the majority of older people develop dehydration as a result of increased fluid losses combined with decreased fluid intake, related to decreased thirst. The condition is rarely due to neglect (Thomas et al., 2008).
Risk Factors for Dehydration
Most healthy older adults maintain adequate hydration, but the presence of physical or emotional illness, surgery, trauma, or conditions of higher physiological demands increase the risk of dehydration. When the fluid balance of older adults is at risk, the limited capacity of homeostatic mechanisms becomes significant (Faes et al., 2007).
Age-related changes in the thirst mechanism, decrease in total body water (TBW), and decreased kidney function increase the risk for dehydration. The loss of muscle mass
with age increases the proportion of fat cells. This loss is greater in women because they have a higher percentage of body fat and less muscle mass than men. Because fat cells contain less water than muscle cells, older people have a decreased intracellular fluid volume.
Thirst sensation diminishes, resulting in the loss of an important defense against dehydration. In a mechanism that is not well understood, thirst in older adults is not
“proportional to metabolic needs in response to dehydrat- ing conditions” (Mentes, 2008, p. 371). Creatinine clearance also declines with age, and the kidneys are less able to concentrate urine. These changes are more pronounced in older people with illnesses affecting kidney function.
Other risk factors for dehydration include medications, particularly those that directly affect renal function and fluid balance (diuretics, laxatives, angiotensin-converting enzyme [ACE] inhibitors) and psychotropic medications that have anticholinergic effects (dry mouth, urinary reten- tion, constipation). The use of four or more medications is also a risk factor (Faes et al., 2007).
Functional deficits, communication and comprehension problems, oral problems, dysphagia, delirium, depression, dementia, hospitalization, low body weight, diagnostic pro- cedures necessitating fasting, inadequate assistance with fluid intake, diarrhea, fever, vomiting, infections, bleeding, draining wounds, artificial ventilation, fluid restrictions, high environmental temperature, and multiple comorbidi- ties have all been noted as risk factors for dehydration in older people (Mentes, 2006; Faes et al., 2007). NPO requirements for diagnostic tests and surgical procedures should be as short as possible for older adults, and adequate fluids should be given once tests and procedures are com- pleted. A 2-hour suspension of fluid intake is recom- mended for many procedures.
Implications for Gerontological Nursing and Healthy Aging
Assessment
Prevention of dehydration is essential, but assessment is complex in older people. Clinical signs may not ap- pear until dehydration is advanced. Attention to risk factors for dehydration in older adults using a screen (Boxes 9-3 and 9-4) is very important. In addition, the MDS has triggers for dehydration/fluid maintenance.
Education should be provided to older people and their caregivers on the need for fluids and the signs and symptoms of dehydration. Acute situations such as vomiting, diarrhea, or febrile episodes should be identi- fied quickly and treated. Older adults over 85 years of
age who have experienced volume deficits, weight loss, malnutrition, or infections, and those with dementia, delirium, and functional impairments are at high risk for dehydration.
Typical signs of dehydration may not always be pres- ent in older people, and most clinical signs and symptoms are not very sensitive or specific. “The large variability in the way different organs are affected by dehydration will cause symptoms to remain atypical in older adults” (Faes et al., 2007, p. 3). Skin turgor, assessed at the sternum and commonly included in the assessment of dehydration, is an unreliable marker in older adults because of the loss of subcutaneous tissue with aging. Dry mucous membranes in the mouth and nose, longitudinal furrows on the tongue, orthostasis, speech incoherence, extremity weak- ness, dry axilla, and sunken eye may indicate dehydration.
However, the diagnosis of dehydration is biochemical (Thomas et al., 2008).
BOX
9-4
Ongoing Management of Oral Intake 1. Calculate a daily fluid goal.• All older adults should have an individualized fluid goal determined by a documented standard for daily fluid intake. At least 1500 mL of fluid/day should be provided.
2. Compare current intake to fluid goal to evaluate hydration status.
3. Provide fluids consistently throughout the day.
• 75% to 80% of fluids delivered at meals and the remainder offered during nonmeal times such as medication times
• Offer a variety of fluids and fluids that the person prefers
• Standardize the amount of fluid that is offered with medication administration—for example, at least 6 oz 4. Plan for at-risk individuals.
• Fluid rounds midmorning and midafternoon
• Provide 2 8-oz glasses of fluid in the morning and evening
• “Happy hour” or “tea time,” when residents can gather for additional fluids and socialization
• Modified fluid containers based on resident’s abilities—
for example, lighter cups and glasses, weighted cups and glasses, plastic water bottles with straws (attach to wheelchairs, deliver with meals)
• Make fluids accessible at all times and be sure residents can access them—for example, filled water pitchers, fluid stations, or beverage carts in congregate areas
• Allow adequate time and staff for eating or feeding.
Meals can provide two thirds of daily fluids.
• Encourage family members to participate in feeding and offering fluids
5. Perform fluid regulation and documentation.
• Teach individuals, if they are able, to use a urine color chart to monitor hydration status
• Document complete intake including hydration habits
• Know volumes of fluid containers to accurately calculate fluid consumption
• Frequency of documentation of fluid intake will vary among settings and is dependent on the individual’s condition. In most settings, at least one accurate intake and output recording should be documented, including amount of fluid con- sumed, difficulties with consumption, and urine specific gravity and color. For individuals who are not continent, teach caregivers to observe incon- tinent pads or briefs for amount and frequency of urine, color changes, and odor and report variations from individual’s normal pattern
Adapted from Mentes JC: Managing oral hydration. In Capezuti E, Zwicker D, Mezey M, et al, editors: Evidence-based geriatric nursing protocols for best practice, ed 3, New York, 2008, Springer; www.consultgerirn.org.
Drugs, e.g., diuretics End of life
High fever
Yellow urine turns dark Dizziness (orthostasis) Reduced oral intake Axilla dry
Tachycardia Incontinence (fear of) Oral problems/sippers
Neurological impairment (confusion) Sunken eyes
BOX
9-3
Simple Screen for DehydrationFrom Thomas D, Cote T, Lawhorne L, et al: Understanding clinical dehy- dration and its treatment, Journal of the American Medical Directors Association 9(5):292-301, 2008.