Connections. Unintended Weight Loss in Older Adults: ADA Evidence- Based Practice Guidelines. Volume 35 Issue 3 Winter 2011

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1 Connections Volume 35 Issue 3 Winter 2011 Chair Update How to Talk to an Administrator FNCE Foundation Dinner Clinical Nutrition Texts Lacking Guidance in the Area of Dysphagia Assessment and Care Linking Evidence Based CPEU Medicine to Geriatric Nutrition Screening The Mini Nutritional Assessment (MNA ) FNCE F. Ann Gallagher Award WINTER UPDATE COMING SOON Look online at for more information under Winter Update This issue will focus on HomeCare and the opportunities available for members. CPEU This Symbol denotes that CPEU credit is available for the article. Go to to take the quiz. by Charlette Gallagher-Allred, PhD, RD, LD Gretchen Robinson, MS, RD, LD Unintended Weight Loss in Older Adults: ADA Evidence- Based Practice Guidelines The American Dietetic Association Unintended Weight Loss (UWL) in Older Adults Evidence-Based Nutrition Practice Guidelines incorporates a five-year systematic review of scientific evidence for the provision of Medical Nutrition Therapy (MNT) in nursing facilities and community based services. These Guidelines were presented at the Food and Nutrition Conference and Expo (FNCE) in Boston, Massachusetts, November 9, This article identifies and explains the evidenced-based recommendations that can guide food and nutrition practice decisions of Registered Dietitians (RDs) and increase the possibility of achieving positive outcomes in the older adult. What is Evidence-Based Dietetic Practice? Evidence-Based Dietetic Practice is defined by ADA as the use of systematically reviewed scientific evidence when making food and nutrition practice decisions by integrating best available evidence with professional expertise and client values to improve outcomes. (1) Practice guidelines represent ADA s rigorous and systematic process of analyzing scientific research representing the latest evidence at the time of publication. Guidelines are not intended to over-rule professional judgment. The independent skill and judgment of RDs must always dictate treatment decisions. When any workgroup sets out to identify evidence-based practice guidelines, they must ask and answer several questions. What is the Target Population for these Guidelines? The target population for the UWL guidelines is adults who are males or females, age 65 and older, with unintended weight loss. These older adults could be living anywhere: independently at home, or at any level of dependency such as home care, assisted living, nursing facilities, etc. In this project the workgroup did not include hospice patients or those who are terminally ill or imminently dying. They did however make allowances in their recommendations for end-of-life care patients in the intervention recommendations for use of enteral nutrition. CPEU Printing and Mailing Courtesy of Abbott Nutrition, Columbus, OH continued on page 2

2 Unintended Weight Loss in Older Adults continued from page 1 What is the Definition for UWL and Why was it Chosen Instead of Involuntary Weight Loss (IWL)? UWL and IWL are both defined as a decrease in body weight that is not planned or desired. Both terms are used interchangeably in research studies, nationally and globally, and there is no universal scientific evidence for using one term instead of the other. The Centers for Medicare and Medicaid Services (CMS) use the term UWL. ADA initially used the term IWL to designate the nutrition diagnosis but changed to UWL in the 3rd edition IDNT Reference Manual. (2) ADA has also approved involuntary as a synonym for unintended. What Guideline Topics Were Chosen and Why? The UWL workgroup asked and developed questions that: 1. Need to be answered, 2. Are critical and applicable to dietetic practice, 3. Can be used in improving MNT and reducing weight loss in older adults, and 4. Have sufficient number and sufficient highly-graded research studies to make a recommendation and defend that recommendation. Asking appropriate and applicable questions is not an easy task. Finding defendable studies can be even more difficult. Several conference calls over several months were needed to identify topics to research; several more months were needed to find and evaluate studies according to defined criteria. Questions were modified several times. Not surprising, several studies and questions overlapped and the same studies often addressed more than one question. The three recommendations on dining opportunities is such an example. In other cases there was simply not enough study data to address some questions the workgroup had hoped to answer. The one recommendation on appetite stimulants is an example of this. In one case the workgroup agreed to accept by consensus the recommendations that another evidence analysis team had developed. The four recommendations on enteral nutrition by the European Society on Parenteral and Enteral Nutrition is an example of this. 3. Nutrition Diagnosis, 4. Nutrition Intervention, and 5. Nutrition Monitoring and Evaluation. Taken together these guideline topics became our Recommendations. Recommendations are stated in a consistent format that includes three components: 1. a basic recommendation statement, 2. (2) a justification statement for the recommendation, and 3. (3) a double rating for the recommendation. The rating can be strong, fair or weak, consensus, or insufficient evidence. The rating also is either conditional or imperative. A definition of each of these ratings can be found on the Evidence Analysis Library (EAL) website. How do the Practice Guidelines Fit within the Nutrition Care Process Model (NCPM)? The NCP is a problem-solving model that Registered Dietitians (RDs) and Dietetic Technicians Registered (DTRs) use to think critically, make decisions to address nutritionrelated problems, and provide safe and effective high-quality nutrition care to achieve positive outcomes for the older adult. The NCP provides the standardized language and format for nutritional professionals.(3) Central to providing nutrition care is the relationship between the older adult and the dietetics professional or team of dietetics professionals. The individual is referred to the dietitian for MNT, which must first be justified. In the case of UWL the workgroup determined that MNT is effective for older adults. The RD and/or DTR will then complete the steps of the NCP in the following order by: (1) performing a nutrition assessment, (2) identifying a nutrition diagnosis, if appropriate, (3) planning and implementing MNT intervention(s), and (4) monitoring and evaluating outcomes.(4,5) What are the Actual Recommendations? Following are the 28 recommendations, the justification statements and the ratings in the five categories that comprise the Practice Guideline on Unintended Weight Loss in Older Adults. In the end, the workgroup asked questions and developed guideline topics in five major categories: 1. MNT and Nutrition Screening, which precede the Nutrition Care Process (NCP), 2. Nutrition Assessment, PAGE 2 - CONNECTIONS WINTER 2011 continued on page 4

3 Chair Update by Brenda Richardson, MA, RD, LD, CD Greetings to DHCC Members, Greetings and Happy New Year. I hope the holidays were a time for enjoying close friends and family. May each of you know that DHCC is here as your dietetic practice group family. DHCC appreciates you and is committed to demonstrating the value of your membership. We look forward to the many opportunities 2011 will bring. This newsletter is filled with wonderful information to assist you in best practice. I thank Bonnie Gunckel, RD, CD, the DHCC Managing Editor, Maggie Gilligan, RD, LDN, DHCC Multi-Media Coordinator, Marla Carlson, DHCC Executive Director and all contributing authors and reviewers for allowing DHCC to continue offer a newsletter that is rated as the most valued benefit provided to our members. Speaking of values, at the DHCC Executive Committee meeting at 2010 FNCE, we discussed the current annual dues of $30.00 for DHCC membership. During our recent member survey, we had many that shared that DHCC membership was very valuable and that $30 per year was very reasonable. We also had a few that shared they did not renew their membership because they felt the annual dues were too high. After much discussion, it was voted not to increase dues for the next year. It was also decided that we need to improve helping all members feel their membership dues are a real value in today s world. As a Dietetic Practice Group (DPG) of the American Dietetic Association (ADA), we offer many services to empower our members to be the nation s food and nutrition leaders. Some of these services include: supporting continued development of leadership and teamwork skills, the Connections newsletter, e- blasts, list-serve, member support, scholarships, donations, networking with allied health care organizations (Centers for Medicare & Medicaid Services [CMS], American Health Care Association [AHCA], American Medical Directors Association [AMDA], Pioneer Network, National Pressure Ulcer Advisory Panel [NPUAP], others), public policy, regulatory readiness, webinars, publications, ASA s Food & Nutrition Conference & Expo [FNCE]/Pre FNCE functions, and many others. So how does DHCC membership compare with some other types of purchases some of us might make? What do we need to compare with other ways we might choose to spend $30.00? In doing a brief internet search, I compared a few items. COST COMPARISONS OF $30.00 ANNUAL MEMBERSHIP IN DHCC Purchase Cost Amount to = $30 Representation for LTC and Public Policy LTC Webinars & Publications Networking Opportunities Sub-units Newsletter List Serve Growth and Development of Leadership Skills Unleaded $2.86/gallon Fuel gallons Specialty $3.00/cup 10 cups Coffee Soda $1.50/ 24 oz sodas Subscription to Nutrition Magazine/ Newsletter $24/yr. 12 months Yes - - DHCC Annual Membership $30/ yr. 12 months Yes Yes Yes Yes Yes Yes Yes So for me, comparing the services and support I receive from DHCC is much more of a value for my $30.00 than 10.5 gallons of gas or 10 cups of a specialty coffee. So my $30 spent for DHCC annual dues is a real value!! continued on page 12 WINTER 2011 CONNECTIONS - PAGE 3

4 Unintended Weight Loss in Older Adults continued from page 2 MEDICAL NUTRITION THERAPY AND NUTRITION SCREENING MEDICAL NUTRITION THERAPY Individualized medical nutrition therapy (MNT) is strongly recommended for older adults with unintended weight loss. Individualized nutrition care, directed by a Registered Dietitian (RD) as part of the healthcare team, results in improved outcomes related to increased energy, protein and nutrient intakes, improved nutritional status, improved quality of life and/or weight gain. Unintended weight loss in older adults is a harmful and degenerative event that should be prevented if at all possible. There are psychological, physical, and environmental factors of UWL that impact nutrition. The assessment of UWL is challenging because of the number of contributing factors, i.e. depression, chewing and swallowing problems, chronic diseases, neurological diseases, hydration status, impaired mobility, delayed wound healing, etc. MNT for unintended weight loss is based on the older adult s individualized nutrition goals determined by the older adult, the dietitian, and the interdisciplinary care team. The primary goal of MNT for UWL is to achieve positive clinical outcomes for older adults. Five studies were evaluated. One study reported that the prevalence of underweight and/or UWL in sheltered housing, including nursing homes, may be as high as 35%. Four studies reported that the RD providing care based on a MNT protocol were more likely to identify UWL, and after the provision of nutrition care for an additional 90 days the residents maintained or gained weight. There may be costs associated with MNT including cost of RD time and costs of therapy. However, it is generally agreed that a percentage of older adults admitted to acute, chronic, and alternate site care settings may have more complications due to poor nutritional status. These complications can lead to increased morbidity, mortality, length of stay, and cost of care. Therefore, timely and appropriate MNT becomes a critical component of quality nutrition care. NUTRITION SCREENING should collaborate with other health care professionals, administrators and public policy decision makers to ensure that all older adults are screened for unintended weight loss, regardless of setting. Weight change is included in virtually all instruments for nutrition risk screening in older adults and studies support an association between unintended weight loss and increased morbidity and mortality. Nutrition screening precedes the NCP because it identifies those older adults who need further nutrition assessment and it can be conducted by individuals other than the RD. Eight studies were evaluated regarding nutritional status and increasing age. The studies reported evidence that the risk of malnutrition and declining nutritional status were associated with adverse cognitive decline, loss of appetite, swallowing problems, low activity level, eating dependency, and admission to healthcare communities. Therefore, screening for these adverse events is of paramount importance. NUTRITION SCREENING INSTRUMENTS should collaborate with other health care team members and policy makers to ensure that nutrition screening tools have been validated in the older population. The Mini-Nutritional Assessment Short Form and the Nutrition Screening Initiative DETERMINE Your Nutritional Health (DETERMINE) instruments are the most widely studied and validated in this population; several other nutrition screening instruments have been developed but not validated in older adults. Nineteen studies were evaluated regarding the use of particular instruments for nutrition screening in older adults. The Mini-Nutritional Assessment Instrument (MNA), the Mini-Nutrition Assessment Short Form (MNA-SF), and the Nutrition Screening Initiative (NSI) DETERMINE Your Nutritional Health (DETERMINE) instruments are the most widely studied and validated in the older adult population. Ten of the19 studies that were evaluated included these instruments. A neutral-quality cross-sectional study by Bauer, et al (6) compared the validity of three nutrition screening instruments: the Mini-Nutritional Assessment (MNA), the Subjective Global Assessment (SGA), and the Ayrshire Nutrition Risk instrument. Screening forms were compared in 121 geriatric patients. The study indicated that there were more patients at risk or malnourished according to the MNA (70%) than the SGA (45%) or the Ayrshire Nutrition Risk (40.3%). The MNA was found by the geriatric assessment team to be the first choice for use in geriatric patients and was considered to be valid for outpatients as well as nursing home and hospital patients as long as the required information could be obtained. Commonly used criteria for a simple nutrition screening instrument include diagnosis; weight and weight change; appetite and food dislikes or intolerances; problems with PAGE 4 - CONNECTIONS WINTER 2011 continued on page 5

5 Unintended Weight Loss in Older Adults continued from page 4 chewing or swallowing; presence of diarrhea or constipation; laboratory values such as cholesterol, hemoglobin, hematocrit, and total lymphocyte count; and need for diet modification and education. The only screening parameters that have been validated are weight change and appetite. Most dietitians report that they do not perform a nutrition screen because of time constraints and lack of a reliable form. Because there is no gold standard for nutritional screening, and because little research has been done to validate or evaluate the nutrition screening process, nutrition screening is an area of needed research. The RD can play a vital role in the screening process by: 1. helping healthcare communities develop a policy for nutrition screening and implementation, 2. (2) evaluating the effectiveness of the instrument used, and 3. (3) assuring that each individual at nutrition risk is referred to the RD and if needed to a multidisciplinary team for early nutrition intervention. Once the screening process identifies that a nutrition problem exists or is highly likely to exist, a nutrition assessment should be conducted. NUTRITION ASSESSMENT The workgroup made five recommendations related to nutrition assessment, the first step in the NCP. ASSESSMENT OF NUTRITIONAL STATUS should ensure that the nutrition assessment of older adults with unintended weight loss includes (but is not limited to) the following: Assessment of the above factors is needed to effectively determine nutrition diagnoses and plan the nutrition interventions; all of these are associated with food/nutrition-related history adverse health effects in older adults. biochemical data, medical tests and procedures anthropometric measurements nutrition-focused physical findings client history. A nutrition assessment is needed to effectively obtain, verify, and interpret data in order to determine a nutritionrelated diagnosis and its cause/etiology, and to plan nutritional interventions. The data collected in the assessment will necessarily vary, based on the practice setting, current individual clinical status, data necessary to support desired clinical outcomes, evidenced-based recommendations, and whether the assessment is an initial assessment or a reassessment.(7) Eight studies were evaluated regarding nutritional status and increasing age. Studies reported evidence of risk of malnutrition, declining nutritional status, and/or adverse health effects in older adults. Types of data collected to assess nutritional status may include but are not limited to the following components (2): Food/Nutrition Related History: food and nutrient intake, medication intake, activity patterns, loss of appetite, eating dependency, decreased ADLs, meal and snack patterns, swallowing problems, food and nutrient administration (diet order, diet experience, eating environment, enteral and parenteral nutrition administration) Biochemical Data, Medical Tests and Procedures: lab data (electrolytes, glucose/ HgbA1c, lipid panel), resting metabolic rate, swallowing evaluation Anthropometric Measurements: height, weight, weight change, usual weight, BMI Nutrition-Focused Physical Findings: general appearance, muscle and fat wasting, oral evaluation Client History: treatments, medication/supplement usage, cognitive decline, depression, hydration status, presence of infections, pressure ulcers, recent hospitalization INSTRUMENTS FOR ASSESSMENT OF NUTRITIONAL STATUS should collaborate with other health care team members and policy makers to ensure that nutrition assessment tools have been validated in the older population. The Mini-Nutritional Assessment is the most widely studied and validated in this population; several other nutrition assessment instruments have also been developed but not validated. Evidence from 21 studies was evaluated to support the use of particular instruments for the assessment of nutritional status of older adults with UWL based on the question. The MNA is the most widely studied instrument in this population and was used in13 of the 21 studies. Several other nutritional assessment instruments have been developed but are not validated. Four of the studies reported that further validation research on these nutrition assessment instruments is needed. continued on page 6 WINTER 2011 CONNECTIONS - PAGE 5

6 Unintended Weight Loss in Older Adults continued from page 5 ASSESS ANTHROPOMETRIC MEASUREMENTS should ensure that older adults are weighed upon initial visit, admission or readmission to obtain a baseline weight, and then weekly thereafter, using standard procedures. Studies support an association between unintended weight loss and increased mortality. Accurate weight measurements are vital to nutritional assessment and care. Five studies support an association between underweight and/or unintended weight loss and increased mortality. One study reported that mortality was 50% for subjects with a BMI equal to or < 20, but additional research suggests that the current BMI thresholds may not apply to the elderly. (8) Two studies report that weight loss was associated with a two- to 20- fold increased risk for death. One study reported that those who were severely underweight were four times more likely to have an UWL of 10 pounds in six months. ASSESSMENT OF FOOD, FLUID AND NUTRIENT INTAKE and/or Dietetic Technician Registered (DTR) should assess and evaluate food, fluid and nutrient intake in older adults with unintended weight loss. Research reports decreased intake of energy and nutrients in older adults who are acutely/chronically ill and/or underweight and those with cognitive impairment and dysphagia. Nine studies were evaluated regarding the assessment of food, fluid, and nutrient intake. Four of the nine studies reported a decreased intake of energy and nutrients in older adults who were acutely/chronically ill and/or underweight. Two of the nine studies reported a decreased intake of energy and nutrients in older adults with cognitive impairment. Two studies reported a decreased intake of energy and nutrients in older adults with dysphagia. All of the studies supported that a longstanding illness was associated with a statistically significant increased risk of undernutrition. METHODOLOGIES FOR ASSESSMENT OF FOOD, FLUID AND NUTRIENT INTAKE To assess food, fluid and nutrient intake in older adults with unintended weight loss, the Registered Dietitian (RD) and/or Dietetic Technician Registered (DTR) should use quantitative methods (such as calorie counts, percentage of food eaten, individual plate waste studies, etc) rather than qualitative methods (such as interviews) over a period of several days. Research supports multiple days of assessment of food and nutrient intake, and studies report that quantitative methods are necessary to provide estimations of energy intake. Fair, Imperative Five studies were evaluated regarding particular methodologies for the assessment of dietary intake in PAGE 6 - CONNECTIONS WINTER 2011 older adults. Two studies support multiple days of assessment of dietary intake. Three studies reported that quantitative methods (such as calorie counts, the percentage of food eaten, and individual plate waste studies) are necessary to provide estimations of energy intake. Further research of dietary assessment methods in older adults with unintended weight loss is needed. NUTRITION DIAGNOSIS The second step of the nutrition care process is nutrition diagnosis. NUTRITION DIAGNOSIS OF UNINTENDED WEIGHT LOSS will use clinical judgment in interpreting nutrition assessment data to diagnose unintended weight loss and/or underweight in the older adult. Studies support an association between increased mortality and underweight (BMI < 20 kg/m2 or current weight compared with usual or desired body weight) and/or unintended weight loss (5% in 30 days, or any further weight loss after meeting this criteria). Studies support an association between increased mortality and underweight (BMI <20 or current weight compared with usual or desired body weight) and/or unintended weight loss (5% in 30 days, or any further weight loss after meeting this criteria). A nutrition diagnosis is articulated by a PES statement where (P) is the problem or diagnosis label, (E) is the etiology, the focus of the intervention, and something that the RD can affect, and (S) is the signs and symptoms that change when the problem is successfully treated. Signs and symptoms are also the focus of the nutrition monitoring and evaluation step of the NCP. Examples of some PES statements for UWL in older adults are: Unintended weight loss related to swallowing disorder as evidenced by refusal of pureed diet and 15 pound weight loss. Unintended weight loss related to impaired nutrient intake as evidenced by recent bowel resection, GI pain, 20 pound weight loss, presence of stage 2 pressure ulcer on the left heal, nausea and vomiting. Unintended weight loss related to lack of appetite as evidenced by 11 pound weight loss in last 7 days, request for frequent pain medication, and less than 25% food intake. continued on page 7

7 Unintended Weight Loss in Older Adults continued from page 6 Altered nutrition-related lab values related to unintended weight loss and cachexia as evidenced by hemoglobin/hematocrit 9.5/26; albumin 2.3; and cholesterol 40. NUTRITION INTERVENTION The third step of the nutrition care process is nutrition intervention. The workgroup reviewed many studies and developed 16 recommendations for nutrition intervention to improve outcomes in older adults with UWL. ESTIMATING ENERGY NEEDS OF HEALTHY OLDER ADULTS When estimating energy needs for weight maintenance of healthy older adults, the Registered Dietitian (RD) should prescribe an energy intake of kcal/kg/day in females and kcal/kg/day in males. Research reports that applying physical activity levels ranging from 1.25 to 1.75 with measured RMR (via indirect calorimetry) in healthy older adults results in these mean total daily energy estimates. Fair, Conditional Seven studies were evaluated regarding the resting metabolic caloric needs of healthy older adults. The recommendations for resting metabolic rate (RMR), as measured by indirect calorimetry, were kcal/kg/day in females and kcal/kg/day in males. RMR data are not appropriate to determine the energy needs of healthy older adults, except for very few individuals, such as those in a comatose state. Therefore, the workgroup looked at caloric needs of healthy older adults with added physical activity factors. Five studies were evaluated regarding the reported activity levels of healthy adults over age 65. Including physical activity factors with RMR in older adults, the mean total daily energy estimates FOR WEIGHT MAINTENANCE are kcal/kg/day in females and kcal/kg/day in males. The workgroup acknowledged that in some individuals, RMR estimation and the activity factor chosen may be inadequate or excessive, and clinical judgment should be used. ESTIMATING ENERGY NEEDS OF UNDERWEIGHT OLDER ADULTS When estimating energy needs for weight maintenance of underweight older adults, the Registered Dietitian (RD) should prescribe an energy intake of kcal/kg/day, or higher energy levels for weight gain. Research reports that applying physical activity levels ranging from 1.25 to 1.5 with measured RMR (via indirect calorimetry) in older adults who are chronically or acutely ill and/or underweight results in these mean total daily energy estimates. Weak, Conditional Five studies were evaluated concerning the caloric needs of older adults who are acutely or chronically ill and/or underweight. Overall the studies had many limitations such as poor control of variables, non-comparable population groups, and inappropriate outcomes measurements. Using best judgment and choosing a physical activity level ranging from 1.25 to1.5, the workgroup estimated the energy needs for weight maintenance of underweight older adults to be kcal/kg/day and higher levels if weight gain is desired. The rating was weak (due to overall poor study design) and conditional as the recommendation applies only to adults over age 65 years who are chronically or acutely ill, and underweight. This is an area that needs better designed research studies and is an area that dietitians can assume an integral role. DINING WITH OTHERS, DINING AMBIANCE, AND CREATIVE DINING PROGRAMS Dining with Others should collaborate with other health care professionals and administrators to encourage all older adults to dine with others rather than dining alone. Dining Ambiance should collaborate with other health care professionals and administrators to promote improvement of dining ambience. Creative Dining Programs should encourage creative dining programs for older adults. Research reports improved food intake and nutritional status in older adults eating in a socially stimulating common dining area. Research indicates that improvements in physical environment and atmosphere of the dining room, food service and meals, and organization of the nursing staff assistance may result in weight gain in older adults. Research indicates that dining programs, such as buffetstyle dining and decentralization of food service, demonstrate improvements in food intake and/or quality of life. The recommendations for Dining with Others, Dining Ambiance, and Creative Dining Programs have to do with the same question, What is the relationship between dining environment and weight gain in adults over age 65? Nine studies were evaluated regarding these three dining conditions, confirming that food intake and nutritional status are improved when older adults eat in a sociallystimulating common dining area, when dining ambiance is improved, and when creative dining programs are implemented. continued on page 8 WINTER 2011 CONNECTIONS - PAGE 7

8 Unintended Weight Loss in Older Adults continued from page 7 The workgroup recognized, however, that all three recommendations, however strong and imperative, may add financial costs. RESIDENT INVOLVEMENT IN MEAL PLANNING should collaborate with other health care professionals and administrators to encourage older adults' involvement in planning menus and meal patterns. Studies show that this may result in improved food and fluid intake. Seven studies were evaluated to determine the relationship between involvement in planning menus and meal patterns and weight gain in older adults. The recommendation that the RD and other health care professionals and administrators encourage older adults involvement in planning menus and meal patterns is supported by the finding that older people eat more and drink more when they are involved in planning menus and meal patterns. DIET LIBERALIZATION For older adults the Registered Dietitian (RD) should recommend liberalization of diets with the exception of texture modification. Increased food and beverage intake is associated with liberalized diets. Research has not demonstrated benefits of restricting sodium, cholesterol, fat and carbohydrate in older adults. The same seven studies that were used to formulate the resident involvement in meal planning recommendation and the benefit or lack thereof of diet liberalization (selective diets and non-restrictive diets) and weight gain in older adults. All seven studies showed that diet liberalization, with the exception of texture modification, improved food and beverage intake. Three of the seven studies report little to no evidence to support use of restrictive diets in elderly. COLLABORATION FOR TEXTURE MODIFIED DIETS should collaborate with the speech-language pathologist and other healthcare professionals to ensure that older adults with dysphagia receive appropriate and individualized modified texture diets. Older adults consuming modified texture diets report an increased need for feeding assistance, dissatisfaction with foods, and decreased enjoyment of eating, resulting in reduced food intake and weight loss. Seven studies were evaluated regarding collaborative involvement of healthcare professionals and recommendation for modified texture diets. The workgroup believes that the these studies provide a very strong rating for working with speech and language pathologists (SLP) and other healthcare professionals. PAGE 8 - CONNECTIONS WINTER 2011 Such collaborative efforts can result in improved food intake, weight gain, greater satisfaction with foods and decreased need for eating assistance when older adults with dysphagia receive appropriate and individualized modified texture diets. The workgroup identified potential risks and harms of implementing this recommendation: facilities may not have access to a SLP, and patient refusal or misclassification of the necessary dysphagia diet may result in aspiration pneumonia due to poor swallowing function. There are potential costs associated with modified texture diets, including specialized preparation techniques and special foods and liquids. EATING ASSISTANCE should collaborate with other health care professionals and administrators to ensure that all older adults who need assistance to eat receive it. Research indicates a positive association between eating dependency and poor nutritional status, especially in older adults with dysphagia who receive modified texture diets. In addition, research reports an association between poor nutritional status, frailty, underweight and/or weight loss with cognitive impairment and a decrease in the activities of daily living, including decreased ability to eat independently. Strong, Conditional The workgroup decided that this recommendation should be titled eating assistance (because these recommendations are older adult person centered) even though CMS has feeding assistance programs, which are healthcare professional based. The workgroup evaluated several studies that addressed the relationship between providing eating assistance for those older adults who need it and weight gain. Eight studies report a positive association between eating dependency and poor nutritional status. Seven studies in older patients with dysphagia who were on modified texture diets were found to be at increased need for eating assistance. Four studies report that residents needing help to eat are more likely to receive assistance when staffing levels are adequate. Coupled with many other studies showing a relationship between poor nutritional status and decreased ability to eat independently, the rating is strong and conditional because it relates to older adults who need assistance to eat. Providing assistance to eat may increase labor costs. continued on page 9

9 Unintended Weight Loss in Older Adults continued from page 8 INDICATIONS FOR MEDICAL FOODS SUPPLEMENTS should recommend medical food supplements for older adults who are undernourished or at risk of undernutrition (i.e., those who are frail, have infection, impaired wound healing, pressure ulcers, depression, early to moderate dementia and/or after hip fracture and orthopedic surgery). Studies support medical food supplementation as a method to provide energy and nutrient intake, promote weight gain and maintain or improve nutritional status or prevent undernutrition. Two positive-quality systematic reviews were evaluated regarding nutritional supplementation in older adults. A systematic review of 21 randomized trials representing 1,727 older adults recovering from hip fracture concluded that some evidence exists for the effectiveness of oral and protein energy feeds, but overall evidence remains weak. (9) A second systematic review of 49 randomized controlled trials representing 4,790 elderly participants concluded that supplementation produces a small but consistent weight gain in older people and may also have beneficial effect on mortality. (10) These results together with the known benefits of nutrient intake resulted in the strong and imperative recommendation that the RD should recommend medical food supplements for older adults who are undernourished or at risk of undernutrition, in patients who are frail, have infection, impaired wound healing, pressure ulcers, depression, early to moderate dementia, and after hip fracture and orthopedic surgery. There are no risks or harms in implementing this recommendation. Nutritional supplements may be financially costly although so are labor costs for institutionally-prepared nutrientdense foods. Especially costly are those supplements or nutrient-dense foods that are prepared, presented to the individual, but are not consumed. NEW PRODUCTS AVAILABLE Practitioner Pocket Guide for MDS 3.0 and Nutrition #5038 $ To order #5038 call ext 5000 Inservice Manual (Electronic Download) #5037 $30.00 Order online at INDICATIONS FOR ENTERAL NUTRITION Indications should recommend consideration of enteral nutrition for older adults who are undernourished or at risk of undernutrition; it is clearly indicated in patients with severe dysphagia. Contraindications Enteral nutrition may not be appropriate for terminally ill older adults with advanced disease states, such as terminal dementia, and should be in accordance with advance directives. Initiation To improve energy and nutrient intake in older adults at nutritional risk, enteral nutrition should be initiated as early as possible after confirming tube placement. Route For older adults with neurological dysphagia and/or if enteral nutrition is anticipated for longer than 4 weeks, the use of a percutaneous endoscopic gastrostomy (PEG) tube is preferable to nasogastric tubes. Studies support enteral nutrition as a method to provide energy and nutrient intake, promote weight gain and maintain or improve nutritional status or prevent undernutrition. The development of clinical and ethical criteria for the nutrition and hydration of persons through the life span should be established by members of the health care team, including the Registered Dietitian (RD). (11) Studies support that enteral nutrition can be initiated 3 hours after a percutaneous endoscopic gastrostomy (PEG) tube is placed, and placement is confirmed. Studies report that PEG tube use is associated with fewer treatment failures and improved nutritional status. Consensus, Conditional Strong, Conditional The workgroup addressed the evidence for potential benefit of enteral nutrition via tube feeding for older adults who are undernourished or at risk of undernutrition. It is important to acknowledge that organizations other than ADA and countries other than the United States have conducted systematic reviews of the literature on several topics, including enteral nutrition. Upon careful evaluation of the methodology, rigor in study evaluation, and grading system consistent with ADA requirements for study evaluation, the UWL workgroup determined that the guidelines written by physicians, nurses, and dietitians of the European Society for Parenteral and Enteral Nutrition (12) were sufficient evidence to determine ADA s recommendations for enteral nutrition in the older adult. It should be noted that the justification for the contraindications recommendation is the statement of the position paper of ADA on ethical and legal issues in nutrition, hydration, and feeding. (11) Risks and harms of implementing these recommendations can be identified, such as inadvertent misplacement of the enteral feeding tube and overfeeding, underfeeding and continued on page 10 WINTER 2011 CONNECTIONS - PAGE 9

10 Unintended Weight Loss in Older Adults continued from page 9 social isolation which may contribute to greater risks of complications over time. Potential costs associated with application were also noted, i.e., enteral nutrition may be more expensive than medical food supplements. The impact of feeding tube placement on cost of medical care has not been adequately evaluated. EVALUATION AND TREATMENT OF DEPRESSION should collaborate with other healthcare professionals to consider evaluation and treatment of depression for patients who are undernourished or at risk of undernutrition when medical nutrition therapy (MNT) interventions have not resulted in improved nutrient intake and/or stabilization of weight. Research reports an association between depression and weight loss or poor nutritional status. Strong, Conditional Depression is a common condition in the elderly and may lead to poor food intake and weight loss. Twelve studies were evaluated and the workgroup concluded that evaluation and treatment of depression may result in improved food intake, weight gain, and improvement of nutritional status. The RD can play a pivotal role in recommending evaluation and treatment of depression when MNT interventions have not resulted in improved nutrient intake and/or stabilization of weight. APPETITE STIMULANTS should collaborate with other healthcare professionals to consider appetite stimulants when medical nutrition therapy (MNT) interventions for older adults have not resulted in improved nutrient intake and/or stabilization of weight. There is no research on the effectiveness of appetite stimulants for older adults that meet the American Dietetic Association criteria for evidence analysis. Consensus, Conditional Even though there was no research that met the ADA criteria for evidence analysis to address the effectiveness of appetite stimulants for older adults, consensus was reached that the RD should collaborate with other healthcare professionals to consider appetite stimulants when MNT interventions have not resulted in improved nutrient intake and/or stabilization of weight. Appetite stimulants may have undesirable side effects and may be costly. The workgroup suggests that dietitians should be involved in research on appetite stimulants and nutritional outcomes. MONITOR AND EVALUATE NUTRITIONAL STATUS The fourth and final step of the NCP is to monitor and evaluate nutritional status. Three recommendations were made in this category. MONITOR AND EVALUATE NUTRITIONAL STATUS should monitor and evaluate the nutritional status of older adults with unintended weight loss, based on the methodology initially used during assessment, including (but not limited to) the following: Monitoring and evaluation of the above factors is needed to determine the effectiveness of medical nutrition therapy (MNT); all of these are associated with adverse health effects in older adults. food/nutrition-related history biochemical data, medical tests and procedures anthropometric measurements nutrition-focused physical findings. Monitoring specifically refers to the review and measurement of the nutritional status of older adults at scheduled follow-up points, pertaining to assessment data, nutrition diagnosis, intervention plans/goals, and outcomes. Evaluation is the systematic comparison of current findings with previous status, intervention goals, or a reference standard. Monitoring and evaluating the nutritional status of older adults with UWL is based on the same methodologies and components used during nutritional assessment (2) Food/Nutrition-Related History: total energy intake, oral fluid/food intake, enteral/parenteral intake, protein intake, diet prescription, medication/herbal supplement intake, food and nutrition knowledge, eating environment, beliefs and attitudes (food preferences) physical activity, nutrition related ADLs, nutrition quality of life responses Biochemical Data, Medical Tests and Procedures: lab data (electrolytes, glucose/ha1c, lipid panel), resting metabolic rate, swallowing study by the speech language pathologist, self-feeding and restorative device evaluation by the occupational therapist Anthropometric Measurements: height, weight, BMI, and weight history/trends Nutrition-Focused Physical Outcomes: physical appearance, skin condition, muscle and fat wasting, swallowing function, appetite, oral health MONITOR AND EVALUATE ANTHROPOMETRIC MEASUREMENTS should monitor and evaluate weekly body weights of older adults with unintended weight loss, until body weight has stabilized, to determine effectiveness of medical nutrition therapy (MNT). Studies support an association between unintended weight loss and increased mortality. PAGE 10 - CONNECTIONS WINTER 2011 continued on page 11

11 Unintended Weight Loss in Older Adults continued from page 10 The current standards of practice recommend weighing the individual using standard procedures upon admission or readmission (to establish a baseline weight), weekly for the first four weeks, and at least monthly thereafter. Unintended weight loss can indicate a nutritional problem. Therefore an accurate weight may be pertinent if there is a significant change in condition, food intake has declined and persisted for more than a week, or if there is other evidence of altered nutritional status or fluid and electrolyte imbalance. Weight monitoring may not be indicated if the individual is terminally ill and requests only comfort care. Most reference tables do not include elderly individuals in their subject pool, and thus these tables are not ageadjusted. Standard height and weight tables and BMI tables are therefore not valid for use in older adults. MONITOR AND EVALUATE FOOD, FLUID AND NUTRIENT INTAKE and/or Dietetic Technician Registered (DTR) should monitor and evaluate food, fluid and nutrient intake in older adults with unintended weight loss, based on the methodology initially used during assessment. Research reports decreased intake of energy and nutrients in older adults who are acutely/chronically ill and/or underweight and those with cognitive impairment and dysphagia. In addition, research supports multiple days of assessment of food and nutrient intake, and studies report that quantitative methods are necessary to provide estimations of energy intake. Research reports that older adults who are acutely/ chronically ill and/or underweight, and those with cognitive impairment and dysphagia are at risk for decreased intake of energy and nutrients. Multiple days of assessment of food and nutrient intake and quantitative methods (calorie counts, plate waste, and percentage of food eaten) are necessary to provide estimates of energy intake. FUTURE APPLICATION OF THE PRACTICE GUIDELINE Currently four members of the initial UWL workgroup are developing a toolkit that provides the RD with guidance in applying the UWL evidenced based recommendations in the provision of Medical Nutrition Therapy to the older adult. Materials in development include screening, assessment, monitoring and evaluation forms. These articles will incorporate steps of the nutrition care process with case studies illustrating nutrition diagnosis and nutrition interventions. Education and resource documents will help RDs individualize a nutrition plan for UWL based on current scientific evidence, clinical judgment and monitoring outcomes. The RD can use the toolkit to train new staff, students and interns; meet regulations based on evidence-based best practice; and help change public policy by advocating for new and expanded coverage for MNT. It is the goal of the work group to develop a toolkit that will become the gold standard for providing medical nutrition therapy to older adults with unintended weight loss. Workgroup Members: Ronni Chernoff, PhD, RD, FADA Krista Clark, RD, LD, CNSD Becky Dorner, RD, LD Charlette Gallagher-Allred, PhD, RD, LD Mary Ellen Posthauer, RD, CD, LD, Chair Gretchen Robinson, MS, RD, LD, FADA Lori Roth-Yousey, MPH, RD, LN, Former Member/Co-chair Erica Gradwell, MS, RD, Project Manager/Lead Evidence Analyst REFERENCES 1. The American Dietetic Association Evidence Analysis Library, accessed November 30, Available at: code=help:faq&highlight=evidence%20based%20dietetic% 20practice&home=1#EBDP%20definition. Accessed 1 December International Dietetics and Nutrition Terminology (IDNT) Reference Manual, 3rd edition. Chicago, IL: American Dietetic Association Lacey K, Pritchett E. Nutrition care process and model. J Am Diet Assoc. 2003;103(8): Bueche J, Charney P, Pavlinac J, Skipper A, Thompson E, Meyers E. Nutrition care process and model, part I: the 2008 Update. J Am Diet Assoc. 2008;108(7): Bueche J, Charney P, Pavlinac J, Skipper A, Thompson E, Meyers E. Nutrition care process, part II: using the International Dietetics and Nutrition Terminology to document the nutrition care process. J Am Diet Assoc. 2008;108(8): Bauer JM, Vogl T, Wicklein S, Trogner J, Muhlberg W, Sieber CC. Comparison of the Mini-Nutritional Assessment, Subjective Global Assessment, and Nutritional Risk Screening (NRS 2002) for nutritional screening and assessment in geriatric hospital patients. Z Gerontol Geriatr. 2005;38(5): Charney P and Malone A. ADA Pocket Guide to Nutrition Assessment, 2nd edition. Chicago, IL: American Dietetic Association. 2009; Sanchez-Garcia S, Garcia-Pena C, Duque-Lopez MX, Juaroz-Cedillo T, Cortes-Nunez AR, Reyes-Beaman S. Anthropometric measures and nutritional status in a healthy elderly population. BMC Public Health. 2007;7: Avenell A, Handoll HHG. Nutritional supplementation for hip fracture aftercare in older people. Cochrane Database Syst Rev. 2006;4:CD Milne AC, Potter J, Avenell A. Protein and energy supplementation in elderly people at risk for malnutrition. Cochrane Database Syst Rev. 2005;2:CD Maillet JO, Potter RL, Heller L. Position of the American Dietetic Association: ethical and legal issues in nutrition, hydration, and feeding. J Am Diet Assoc. 2002;102(5): Volkert D, Berner YN, Berry E, Cederholm T, et al. ESPEN guidelines on enteral nutrition: geriatrics. Clin Nutr. 2006;25(2): WINTER 2011 CONNECTIONS - PAGE 11

12 Chair Update continued from page 3 DHCC will continue to grow the services offered to members. The DHCC Program of Work is reviewed annually with input from the EC and all member surveys/input. DHCC s annual Program of Work is primarily financially supported from membership dues, and sponsorships. So to help us grow our services and keep dues at $30 per year, we really need your help. Here is how each member can help: 1. Continue to let us know what your needs are. 2. Tell others about the value of membership in DHCC. 3. Do not give away your membership to nonmembers by sharing publications, tools and resources. (This dilutes our ability to have funding for overall services) 4. Explain to potential members that especially in today s ever-changing healthcare community, that DHCC is their professional home. 5. Refer potential members to our Executive Director Marla Carlson at carlsonmom@mchsi.com. Marla will send any questions etc. to the appropriate DHCC EC members for prompt support and assistance. Last but not least, be sure to check out the many opportunities for you to get involved with DHCC. DHCC offers many ways for you to network, and grow your skills. DHCC will allow you to grow friendships that last a lifetime. Be sure to contact any of the DHCC Executive Committee (EC) members if you have questions or need assistance. The DHCC EC is a dynamic group of committed professionals that truly care about the members and the profession. It continues to be an honor being able to serve with such an inspiring group that teaches me new skills each day. It also continues to be an honor to serve you as DHCC Chair for Brenda Richardson, MA, RD, LD, CD FNCE Foundation Dinner Cynthia Piland, MS, RD, CSG, LD; Sharon Emley, MS, RD, LD; Brenda Richardson, MA, RD, LD, CD How to Talk to an Administrator by Kathy Weigand, RD, LDN and Mary Rybicki, MS, RD, LDN The current healthcare environment with its reimbursement constraints, as well as the recent downturn in the country s economy, has increased the skilled nursing facility s administrator and/or owner s interest in obtaining the best possible value for dollars spent. The registered dietitian s (RD) services fall within this realm. Because RD services are not reimbursed in the skilled nursing setting, a tangible financial impact on the bottom line must be part of the justification for additional hours. This is in addition to the obvious value and benefit to the residents. Talking points and considerations for meeting with a new client may include the following: Assessing an RD position: How to prepare for a sales call to a potential new client: 1. Research the facility online and examine past survey records PAGE 12 - CONNECTIONS WINTER MapQuest to determine time and mileage commitment 3. Update your resume, references; take notes on relation to current position 4. Prepare your answers for standard questions: why are you the best dietitian for this job; why did you leave your other jobs; how did you contribute? How will you fit this new facility into your schedule? 5. Calculate how much time it will take to provide services to the facility. 6. Calculate contracted pay and hours to be worked. What is your daily hourly rate plus travel and expenses? Questions to consider asking to evaluate an RD position 1. What is the average census? Average length of stay? 2. How many admissions monthly? 3. What meetings does the RD attend weekly and how much time is scheduled for each meeting? continued on page 22

13 Clinical Nutrition Texts Lacking Guidance in the Area of Dysphagia Assessment and Care by Barbara Sanchez and Victoria Castellanos, PhD, RD Introduction Approximately 10 million Americans suffer from dysphagia, which makes it difficult for them to consume sufficient food and water to meet their nutrient needs. Since many dietitians will be working with clients with dysphagia in their practice setting, it is important that dietetics training cover this topic with sufficient depth and breadth. Although there is little published research to guide evidence-based practice in the area of dysphagia management, textbooks used to train dietetics students should cover best practices in a comprehensive manner so that the entry-level RDs are adequately prepared to provide care to this population. This study was performed to evaluate the depth and breadth of information on dysphagia contained in commonly used dietetics textbooks and to compare this information to the guidance provided in the 2009 International Dietetics and Nutrition Terminology Reference Manual: Standardized Language for the Nutrition Care Process (IDNT). Methods During the summer of 2009, six clinical nutrition textbooks were identified by a sample of DPD programs as being commonly used in dietetics curriculum. The latest editions of the textbooks were reviewed. Textbooks were number coded from 1-6 to protect anonymity. Information regarding dysphagia was located in the texts by the following terms in the index: dysphagia, swallowing, swallowing problems, and elderly. Once the dysphagia information was located, the relevant information in the textbooks was organized and discussed according to four steps of the Nutrition Care Process (NCP): assessment, diagnosis, intervention and monitoring/evaluation. A summary of the information included in the texts is included in the table. Discussion On the topic of assessment of patients with dysphagia and diagnosis of a nutrition problem, the textbooks focused on the assessment performed by the SLP and failed to discuss the nutritional assessment that should be done by the RD. Only one text provided any information relative to nutrition problems that commonly occur in individuals with dysphagia. The IDNT manual indicates a wide range of assessments that are commonly performed by the RD when someone has swallowing difficulty, including diet order, diet experience, meal behavior, nutrition-focused physical findings and social history. It would be ideal if all texts provided guidance regarding common nutritional problems to look for in this population and what assessment values would constitute evidence of a nutrition problem that could be addressed by the nutrition professional. The texts do a little better job regarding the intervention step of the NCP than they do the assessment step, although the focus is almost completely on texture modification. Only one of the texts emphasizes the importance of the nutritional adequacy of the diets and only one text mentioned quality of life issues. It has been previously suggested that that primary goal of nutrition interventions for individuals with dysphagia is to achieve adequate nutrition and hydration status, not to prevent aspiration (Castellanos et al., 2003). For the quality of life of the patient it is also important that individual preferences and tolerance of specific foods be taken into consideration in the intervention step. Only 50% of the texts addressed the monitoring/evaluation step of the NCP: three of these mentioned monitoring adequacy of nutrient and water intake; two mentioned monitoring for evidence of continued difficulty swallowing food; and two mentioned monitoring for evidence that texture modification may need to be increased or decreased in response to a change in impairment. Ideally all clinical nutrition texts would provide guidance in these and other aspects to be routinely monitored. In sum, the information contained in the individual textbooks was wholly inadequate as a resource for students or practitioners regarding the assessment, treatment and monitoring/evaluation of patients with dysphagia. Further, the text material did not conform to the NCP format, and there were few similarities between the information in the texts and the guidance provided by the IDNT manual. Conclusion Although practice will continue to be challenged by a lack of published research regarding the nutritional management of dysphagia, it would be of benefit to both students and practitioners if textbooks used to train students were more thorough and systematic in their coverage of the assessment, diagnosis, intervention and monitoring/evaluation steps of the Nutrition Care Process for patients with dysphagia. It would be ideal if practitioners with expertise in the nutrition problems commonly encountered by older adults were asked to contribute, or at least review, the content of clinical nutrition texts to assure that these topics are adequately covered. continued on page 14 WINTER 2011 CONNECTIONS - PAGE 13

14 Clinical Nutrition Texts Lacking Guidance in the Area of Dysphagia Assessment and Care continued from page 13 Textbooks Paraphrased Textbook Statements ASSESSMENT 1, 4, & 5 Refers to assessment by SLP 3, 4, & 5 Describes the signs and symptoms of dysphagia. Only one reference describes signs and symptoms of any nutrition problems 2 States proper screening and management of dysphagia can expedite the recovery process 2 States misdiagnosis not only impedes nutritional status, but it is also associated with other complications such as aspiration and pneumonia DIAGNOSIS 4 Inadequate dietary intake, weight loss, nutrient deficiencies, PEM, and dehydration may result from prolonged dysphagia. INTERVENTION 1 Informs that there are a variety of thickening agents and specialized products pre-prepared to meet specific consistency for the diets. 1 Refers reader to Dysphagia diet 1, 2, 3. 1, 2, 4, 5, Modify consistency/texture, discussion of thickeners 6 1, 2, 6 Refer reader to National Dysphagia Diet 2, 4 Avoid thin liquids, prevent aspiration 2,4 Individualize diet to achieve safe swallow, adequate hydration and patient preferences 3 Consider carb content of thickeners when planning carb-restricted diets. 3 Enteral feeding may be necessary to supplement until person can eat adequate amounts 4 For some pt's, thin liquids may be needed. 4,5 Provide foods that stimulate swallowing reflux 4 Diet should promote weight maintenance, support independence, correct current deficits, Use kcal/kg and g protein MONITORING/EVALUATION 1 Aspiration or inhalation of orophayngeal contents is a primary complication - monitor 1, 4 Inadequate intake, weight loss, dehydration, PEM, nutritional deficiencies (esp A & C) may result. 3 Diet is nutritionally adequate, meets DRIs 3 Monitor adequacy of fluid intake, adequacy of calories, pro, vit, and minerals. 4 Monitor for pocketing of foods 4 Monitor cardiac, renal and liver status 1, 4 Under guidance of SLP, modify levels of dysphagia diets as impairment level changes References Castellanos VH, Silver HJ, Gallagher-Allred C, Smith TR. Nutrition Issues in Home, Community, and Long Term Care Settings. Nutr Clin Pract. 18:21-36, International Dietetics and Nutrition Terminology Reference Manual: Standardized Language for the Nutrition Care Process (IDNT). 3rd Edition, 2009, American Dietetic Association Barbara Sanchez is a master s student at Florida International University (FIU) in Miami. Victoria Hammer Castellanos, PhD, RD, is Associate Dean of the University Graduate School and Associate Professor in the Department of Dietetics and Nutrition at FIU. Castellanos research group, and collaborating LTC practitioners, is using a multifaceted and evidence-based practice approach to solving the nutrition-related problems of older people in nursing homes and in home- and community-based settings. Remember to Vote! Make your voice heard by electing future leaders. ADA and Dietetic Practice Group/Member Interest Group (DPG/MIG) online elections begin February 1-March 3, 2011, so please remember to vote! To vote, visit: and select Vote Now, then enter your ADA member number. If you have questions about voting in the DPG/MIG elections contact practice@eatright.org. Remember, your vote shapes the future of DHCC DPG. Voting ends March 3. PAGE 14 - CONNECTIONS WINTER 2011

15 Linking Evidence Based Medicine to Geriatric Nutrition Screening The Mini Nutritional Assessment (MNA ) by Janet Skates, MS, RD, LND, FADA, Nutrition Consulting Services, Kingsport, TN Patricia Anthony, MS, RD, Nestlé Nutrition, Vevey, Switzerland CPEU Sources of support: Nestlé Nutrition This article is reprinted with permission from the Indiana Dietetics in Health Care Communities dietetic practice group and Healthy Aging dietetic practice group. It originally appeared in the spring 2009 edition of The Spectrum, newsletter of Healthy Aging DPG and was updated and reprinted in the summer 2010 edition of The Hoosier, newsletter of the Indiana DHCC. Ó2009, The Spectrum Newsletter; Healthy Aging, a dietetic practice group of the American Dietetic Association. Used with permission. Ó2010, The Hoosier Newsletter; Indiana Dietitians in Health Care Communities, a state affiliate of the DHCC dietetic practice group of the American Dietetic Association. Used with permission. INTRODUCTION With the number of persons 65 years and older expected to double in coming decades, there is growing interest in the United States on containing healthcare costs for the elderly by increasing support to maintain them in community settings. The success of this shift in care depends on elders being able to maintain functional status. This occurs at a time when many older persons face failing health or other physiological or psychosocial changes that can lead to undernutrition. If undetected and untreated, progressive undernutrition can lead to malnutrition and cause loss of independence, lower quality of life, increased institutionalization, and death. This scenario presents opportunities for Registered Dietitians (RD) to demonstrate their value by designing effective nutrition programs that can help older Americans maintain or restore their nutrition status and maximize independent function. The first step is effective nutrition screening that quickly and accurately identifies those elders who are at risk for malnutrition so they can receive intervention early, when it is most effective. The causes of malnutrition in the aging population vary from physical reasons to social and psychological reasons that affect functionality (Table 1). Because each cause has a different treatment, screening tools should use multiple measures to detect specific causes of malnutrition. This article discusses the Mini Nutrition Assessment (MNA ), a nutrition screening tool developed specifically for persons 65 years and older, that helps the RD to target nutrition interventions to specific causes of malnutrition identified by specific questions in the MNA. Pinpointing the causes of malnutrition helps the RD make accurate nutrition diagnoses and implement early intervention, without wasting resources on those who need no intervention. DESCRIPTION AND USE The MNA is a nutrition screening tool that is specifically designed to identify malnutrition in the older adult age 65 and over. The MNA (Figure 1) focuses on six variables that together identify malnutrition in the elderly weight loss, body mass index (BMI) or calf circumference (CC), appetite, disease, dementia or depression, and immobility. The first three variables evaluate indicators of past nutrition status (weight loss), present nutrition status (BMI or CC) and potential future nutrition problems (appetite); the last three variables assess important age-related factors that negatively impact nutrition in the elderly (disease, dementia or depression, and immobility). Over time, the MNA has evolved in three steps - from the original full 18-item questionnaire to a two-step process, in which a shortened form of the MNA, the (MNA -SF), was used as a first step to screen out low-risk persons, to the recently revised MNA -SF, which can be used as a standalone tool to identify the malnourished, thereby shortening the time to accurately screen older adults and implement care. The original full MNA included 18 total questions and had a maximum combined total score of 30; a total score from 24 to 30 indicated adequate nutritional status, scores between 17 and 23.5 indicated risk for malnutrition, and scores less than 17 indicated malnutrition. However, the full MNA took too long for clinical use, so researchers introduced a short form of the MNA, made up of the 6 most strongly correlated questions from the original MNA. The MNA -SF preserved the accuracy and validity of the full MNA and saved time in screening out well nourished people. However, the 2-step process remained underutilized in clinical practice because the full MNA had to be completed to differentiate between those who were nutritionally at risk and those who were malnourished. Recently, the MNA -SF was revised and revalidated as a stand-alone screening tool. The new form incorporates 3 cut-off points, which allows clinicians to identify those who are malnourished without completing the full MNA. With a maximum score of 14, scores of indicate well nourished, scores of 8-11 indicate nutrition risk, and scores of 0-7 indicate malnourished. Unlike the original MNA -SF, the new form allows calf circumference to be substituted when BMI is not available. With the recent revisions, the new MNA -SF now facilitates screening in less than 5 minutes and makes the link to intervention easier. continued on page 16 WINTER 2011 CONNECTIONS - PAGE 15

16 Linking Evidence Based Medicine to Geriatric Nutrition Screening continued from page 15 DEVELOPMENT AND VALIDATION OF THE MNA The original MNA was developed in the 1990 s and was validated in large representative samples of elderly persons worldwide. The tool was comprised of the items listed in Figure 1 plus biochemical markers and was compared with two criteria - clinical status and a battery of anthropometric, dietary, and biochemical indices (Table 2). Clinical status, as defined by a physician, was considered to be the gold standard to define malnutrition risk. The development study showed the MNA correlated strongly with conventional nutrition assessment (biochemical data, dietary intake, and anthropometric parameters) and also with clinical status. The MNA does not include laboratory data as exclusion of this information did not change the strength of the tool and thus makes it a more practical tool. The sensitivity, specificity, and positive predictive value according to clinical status were 96%, 98%, and 97% respectively. Additional validation studies among both frail and healthy older persons confirmed the usefulness of the MNA in clinical practice. The MNA agreed with physicians ratings of clinical status nearly 90% of the time. Even without laboratory data, the MNA correctly classified between 70% and 75% of all healthy and frail participants as normal or malnourished. The remaining 25% - 30% could not be definitely classified as either normal or malnourished; but were identified as at risk for malnutrition even before they lost weight or had changes in their serum albumin levels. This ability of the MNA to predict malnutrition before marked changes in weight or albumin level occur has proven to be a key benefit in clinical practice. The validity of the original MNA -SF was established by comparing it to the full MNA. Results showed the MNA - SF correlated strongly with the full MNA score and other nutritional parameters. Its high sensitivity and specificity, compared with the full MNA, indicated it was a valid screening tool. The recent revision and revalidation of the MNA -SF confirmed a strong correlation between the MNA and nutrition parameters, such as albumin and C-reactive protein. Statistical analysis showed the revised MNA -SF retains the validity and reliability of the original MNA in identifying elderly patients who were well-nourished, at-risk for malnutrition, or malnourished. Furthermore, in those patients for whom a BMI cannot be obtained, the study showed that calf circumference is an acceptable alternative. PAGE 16 - CONNECTIONS WINTER 2011 THE IDEAL SCREENING TOOL HOW DOES THE MNA MEASURE UP? The ideal nutrition screen may vary according to the targeted population, the care setting, and the purpose of the screening. While nutrition screening in a hospital is designed to identify patients who may benefit from nutritional support, screening tools in the community setting should be more focused on identifying individuals who are malnourished or nutritionally at risk. To be effective, the ideal screening tool should meet the criteria in Table 3. - The MNA is well validated and is supported by more than 400 published studies. In contrast, most nutrition screening tools in practice have not been validated. Why is validity important when selecting the best tool for screening a given population? Validated tools have proven they actually measure what they claim to measure in a specific population. By using validated tools, clinicians are more likely to correctly identify clients who truly need help, avoid missing those who need intervention, and begin intervention earlier when the potential for recovery is greater. They are less likely to waste resources on those who do not need intervention. Validated nutrition screening tools support evidence-based dietetics practice and facilitate decisionmaking based on the best available, valid, and relevant evidence. Validity is measured by sensitivity and specificity and by predictive value, which range from 0 100%. Sensitivity is the effectiveness of a test in detecting a disease in those who have the disease. The higher the sensitivity of a nutrition screening tool, the fewer true cases of nutrition risk go undetected. Specificity is the extent to which a test gives negative results in those that are free of the disease. The higher the specificity of a nutrition screening tool, the fewer well-nourished people are labeled as at nutrition risk.9 Positive predictive value is how many of the subjects who test positive truly have the disease. Negative predictive value is how many of the subjects who test negative truly do not have the disease. Ideally, a screening test should be highly sensitive and highly specific and have both positive predictive value and negative predictive value. Reliability is an important measure in assessing the accuracy of a nutritional screening tool. The tool should give the same results every time it is used. Inter-rater reliability measures the agreement between the results when more than one user applies it to the same subject. The MNA consistently demonstrates a high level of reliability. continued on page 17

17 Linking Evidence Based Medicine to Geriatric Nutrition Screening continued from page 16 A nutrition screening tool should also provide an acceptable measurement of the condition being studied. A key determinant of reported prevalence of malnutrition is the cut-off level for body mass index (BMI) that defines malnutrition. The MNA s cut-point to define risk for malnutrition is BMI <22kg/m2, which has been shown to correctly identify clinical malnutrition in elderly patients with acceptable sensitivity and specificity. Lower BMI cut points for malnutrition, used in other screening tools, may be more reflective of the general population and not specifically geriatrics. This geriatric specific cut off may account for the higher reported prevalence of malnutrition with the MNA, which is consistent with a higher prevalence of nutrition issues in the geriatric vs. the general adult population. The ideal screening tool should be specific for the population that the tool is targeting. The MNA was specifically designed for the elderly and has been studied more than any other screening tool for older people.5 Screening tests should have clearly defined thresholds. Cross tabulation of the MNA score and serum albumin concentration in individuals without inflammation established thresholds that clearly distinguish those with adequate nutrition status vs. malnutrition vs. risk for malnutrition. Using albumin levels to establish the thresholds was appropriate as they are highly prognostic for morbidity and mortality in the elderly. Cut points for the revised MNA -SF were compared to those obtained with the full MNA. Results showed 80% correct classifications and no complete misclassifications when using BMI and 73% correct classification and no complete misclassifcations when using CC, confirming the validity of the MNA - SF s clearly defined thresholds. In today s environment, screening tests have to be quick and easy to use to be routinely incorporated into busy practice settings. The revised MNA is quick and requires no special skills or calculations, so nurses, dietitians, technicians, and other staff can easily complete the MNA screen in less than 5 minutes. A convenient table allows users to rapidly determine body mass index (BMI), eliminating the need to perform any calculations. Easy-to-follow directions for performing anthropometric measures, even in challenging patients such as those with amputations or who are bed-bound, are available in the user-friendly guidelines which are downloaded from the MNA website ( The MNA Website ( resources include MNA forms in more than 20 languages, interactive MNA forms, access to literature, guides to interpret the MNA, and suggested guidelines for intervention. The MNA is free to use and widely available for all practice settings. Because it does not rely on laboratory data, the MNA is ideal for community and ambulatory care settings, such as assisted living facilities and senior feeding programs, where resources for blood sampling may be limited or cost prohibitive. The ideal screening tool must be effective. Compared with other nutrition screening tools, the MNA is more likely to identify risk of developing undernutrition at an early stage so intervention can be started early when it is most effective. It is useful for follow-up and for monitoring the effectiveness of nutrition intervention. In recent studies, MNA scores improved in patients who received nutrition intervention after being identified by the MNA to have early malnutrition. The MNA predicts not only nutritional risk, but also outcomes of nutrition risk - functional problems, hospitalization, and mortality. Low MNA scores correlate with decline in functional ability, cognitive impairment, and increased frailty in older persons. In hospitalized patients, low MNA scores are predictive of adverse outcomes, including prolonged lengths of stay, increased frequency of discharges to a nursing home, and a nearly three-fold increase in mortality. CHALLENGES IN PRACTICE Because the MNA was specifically developed for use in persons over 65 years of age, it is not suitable as a universal screen for all ages and disease states. Completing the MNA may be challenging in cognitively impaired patients who can not provide reliable answers to the subjective questions about personal nutrition and general health. However, if a caregiver can provide accurate input and all questions on the form are answered, the MNA is considered the best tool to use for geriatric patients. In addition, the MNA was not designed for persons receiving enteral tube feedings; these high-risk patients should receive ongoing full nutrition assessment and follow-up by a R.D. NEW OPPORTUNITIES FOR USING THE MNA Although the MNA has been widely studied in research continued on page 18 WINTER 2011 CONNECTIONS - PAGE 17

18 Linking Evidence Based Medicine to Geriatric Nutrition Screening continued from page 17 settings around the world, it has not been used as extensively in clinical practice in the US. It should be an essential component of every comprehensive geriatric assessment, along with the Mini Mental State Evaluation (MMSE), Geriatric Depression Scale, and Activities of Daily Living (ADLs). There is growing interest in using the MNA in long term residential care and sub-acute care facilities where malnutrition is extremely common and contributes to longer lengths of stays and more frequent readmissions to acute care. The sensitivity and specificity of the Minimum Data Set (MDS) trigger system has been problematic, and although the use of the MDS is mandatory in long term care, it follows that the concomitant use of a well-validated screen, such as the MNA -SF, to accurately identify malnutrition would strengthen the quality of nutrition care, reduce the risk of missing patients with malnutrition, and avoid wasting resources on those who are not at risk. Likewise, the phenomenal growth of the assisted living industry presents an unprecedented opportunity for using the MNA to screen for malnutrition. Unlike long term care and sub-acute care, the assisted living industry is largely unregulated and does not have mandated nutrition screening in place. More widespread use of the MNA would seemingly be welcomed in this setting where high value is placed on maintaining residents functional status to prevent transfer to more costly nursing home care. SUMMARY Malnutrition is a serious problem in many older adults that negatively impacts quality of life, functionality, and the ability to live independently. Many times malnutrition is reversible, and this calls for valid, effective screening tools to detect malnutrition. The MNA fulfills many criteria for an ideal screening tool for the elderly and is recommended by international organizations, including ESPEN and ADA s Evidence Analysis Library It provides a simple, noninvasive, inexpensive, easy-to-use nutrition screening tool that is highly specific, reliable, and well validated. The MNA can quickly and easily identify older adults (over 65 years of age) who are at risk for malnutrition. Among the nutrition screening and assessment tools available to the Registered Dietitian, the MNA must be regarded as the most established nutrition screening tool for the older population. Acknowledgement: The MNA was developed by the Nestlé Research Center, in collaboration with clinicians at the University of Toulouse, France and the University of New Mexico. It is the property of Nestlé S.A. continued on page 19 Perhaps the MNA s greatest potential is in screening and assessment of communityliving older individuals. Its proven ability to identity risk of developing undernutrition at an early stage fits well with the increased emphasis being given to prevention under Medicare and federal initiatives such as the Administration on Aging s home and community based long-term care programs that are designed to address the projected staggering increases in health care spending for aging boomers. Helping high-risk older adults avoid unnecessary placement in nursing homes by identifying and treating malnutrition risk early is consistent with AOA s long-range vision of having a long-term care service system that is person-centered, consumer-directed and helps people at risk of institutionalization to continue to live at home for as long as possible. NEW! You Spoke, We Listened Submitting Nominations for National Honors and Awards Just Got Easier! ADA is shining the spotlight on outstanding food and nutrition practitioners and supporters of the profession through its National Honors and Awards program. Don t miss this chance to honor those who have advanced the profession, exhibited leadership and shown devotion to serving others in both dietetics and allied fields. You may now submit your nominations entirely online! The submission deadline is midnight Central Standard Time on March 1, Award recipients will be announced in May 2011 and recognized at the ADA 2011 Food & Nutrition Conference & Expo in San Diego, CA. Visit our website to learn more and to submit your honors and awards nominations online: PAGE 18 - CONNECTIONS WINTER 2011

19 Linking Evidence Based Medicine to Geriatric Nutrition Screening continued from page 18 Table 1. Effects of Aging on Nutrition Possible Changes with Aging Effect on Nutrition Sensory Impairment Decreased sense of taste Decreased sense of smell Loss of vision and hearing Oral health/dental problems Reduced appetite Reduced appetite Decreased ability to purchase and prepare food Difficulty chewing, inflammation, poor quality diet Change in energy needs Decreased physical activity Muscle loss (sarcopenia) Isolation / depression Financial constraints Diet lacking in essential nutrients Progressive depletion of LBM and loss of appetite Decreased functional ability, help needed with ADLs Decreased appetite Limited access to food; poor quality diet Cumulative Effect Progressive Undernutrition Reprinted with permission from the MNA website ( Table 2. Anthropometry Functional evaluation Dietary evaluation Clinical evaluation Biochemical markers Principle Criteria Used to Validate the MNA Weight, height, body mass index (BMI), mid-arm circumference (MAC), calf circumference (CC), mid-arm muscle circumference (MAMC), triceps skinfold (TSF), subscapular skin fold (SSF) Mini-Mental State Examination (MMSE), Activities of Daily Living (ADL), Instrumental Activities of Daily Living (IADL) Dietary history, 3-day food record, food-frequency questionnaire, Calculation of daily energy, fluid, macro- and micronutrient intake Clinical status including review of patients medical records Hematocrit, hemoglobin, full blood cell count and blood cell differentiation, total protein, albumin, prealbumin (transthyretin), transferrin, ceruloplasmin, retinol-binding protein, C-reactive protein, 1 -acid-glycoprotein, creatinine, cholesterol, triglycerides, -glutamyl transferase, vitamins A, B 1, B 2, B 6, B 12, D, E, folate, copper, zinc. Activation coefficients for vitamins B 1, B 2, and B 6. Adapted from: Guigoz Y, Vellas B, Garry PJ. Mini nutritional assessment : A practical assessment tool for grading the nutritional state of elderly patients. Facts Res Gerontol 1994;(Suppl 2): continued on page 20 WINTER 2011 CONNECTIONS - PAGE 19

20 Linking Evidence Based Medicine to Geriatric Nutrition Screening continued from page 19 Table 3. Characteristics of Ideal Nutrition Screening Tool Valid and reliable scale in the intended population Minimal bias due to the data collector Accurate Clear definition of thresholds Easy to use and administer by available staff Low associated cost Relevant to outcomes Acceptable to patients Sensitive to change in score Adapted from: Thomas DR. Nutrition assessment in long-term care. Nutr Clin Pract. 2008;23: , and Gans KM, et al. Rate your plate: A dietary assessment and educational tool for blood cholesterol control. Nutrition in Clinical Care 2000;3: Selected References 1 Guigoz Y, Vellas B, Garry PJ. Mini Nutritional Assessment: a practical assessment tool for grading the nutritional state of elderly patients. Facts Res Gerontol 1994;(suppl 2): Vellas B, Guigoz Y, Garry PH, et al. The Mini Nutritional Assessment (MNA) and its use in grading the nutritional state of elderly patients. Nutrition 1999;15: Guigoz Y, Vellas B, Garry PJ. Assessing the nutritional status of the elderly: the Mini Nutritional Assessment as part of the geriatric evaluation. Nutr Rev 1996;54:S59-S65. 4 Kaiser MJ, Bauer JM, Rämasch C, et al. The short-form Mini Nutritional Assessment (MNA-SF): Can it be improved to facilitate clinical use? J Nutr Health Aging. 2009; 13(suppl 2): S16. 5 Thomas DR. Nutrition assessment in long-term care. Nutr Clin Pract. 2008;23: Gans KM, et al. Rate your plate: A dietary assessment and educational tool for blood cholesterol control. Nutrition in Clinical Care 2000;3: Guigoz Y. The Mini Nutritional Assessment (MNA ): review of the literature what does it tell us? J Nutr Health Aging. 2006;6: Bauer JM, Kaiser MJ, Anthony P, Guigoz Y, Sieber CC. The Mini Nutritional Assessment Its History, Today s Practice, and Future Perspectives. Nutr Clin Pract 2008;23: Weekes CE, Elia M, Emery PW. The development, validation and reliability of a nutrition screening tool based on the recommendations of the British Association for Parenteral and Enteral Nutrition (BAPEN). Clin Nutr. 2004;23: Persson MD, Hytter-Landahl A, Brismar K, Cederholm TE. Nutritional supplementation and dietary advice in geriatric patients at risk of malnutrition. Clin Nutr 2007;26: Donini LM, Savina C, Rosano A, et al. MNA predictive value in the follow-up of elderly patients. J Nutr Health Aging 2003;7: Kagansky N, Berner Y, Doren-Morag N, et al. Poor nutritional habits are predictors of poor outcomes in very old hospitalized patients. Am J Clin Nutri 2005;82: Thomas DR, et al. Malnutrition in sub-acute care. Am J Clin Nutri 2002;75: Kondrup J, Allison SP, Elia M, Vellas B, Plauth M. ESPEN guidelines for nutrition screening. Clin Nutr. 2002;22: American Dietetic Association Evidence Analysis Library. Unintended Weight Loss (UWL) in Older Adults: Nutrition Screening. Available at Accessed August 3, PAGE 20 - CONNECTIONS WINTER 2011 continued on page 21

21 Linking Evidence Based Medicine to Geriatric Nutrition Screening continued from page 20 WINTER 2011 CONNECTIONS - PAGE 21

22 How to Talk to an Administrator continued from page What are the best days of the week to have an RD in the facility? 5. How does the process of completing the MDS occur? What is the RD s role in completing the MDS and CAA s? How many per week are completed? 6. What computer access / work space is available for the RD? 7. What computer applications are in place for the dietary department? 8. What staff works on the computer? Who needs additional training? 9. How does the admission process occur and how is the dietary department involved? 10. How are food preferences obtained? Updated? 11. What are the expectations for quality checks done by the RD in the kitchen? 12. What process has worked best for obtaining routine weights? Is there a computerized system for recording and determining weight trends? 13. How does nursing communicate nutritional concerns to the dietitian? How are RD recommendations communicated to nursing and what is the process for nursing to follow through on the recommendations? 14. What are the documentation/assessment expectations for the RD within 7 days of admission; quarterly; biannually? How do the nurses communicate at-risk residents, and on average how many people are referred weekly? And the big questions: 15. What are your goals for the RD? What changes would you like to see? What should remain unchanged? 16. What are your goals for the dietary department and how do you see the RD assist with reaching these goals? 17. Do you have certain projects or concerns regarding the dietary department that are your priorities? What is/are the time frame(s) for these? 18. What are the long term goals for the facility? Reassessment of time required for an existing position: How to talk to the administrator about increasing dietitian hours Remember: an increase in expenses involving RD hours should be related to improvement in services, compliance with state and federal regulations, and adherence to PAGE 22 - CONNECTIONS WINTER 2011 standards of practice. In order to justify an increase in hours, some basic information must be gathered. This information should be as objective as possible. Some examples could be: number of new admissions assessed this year versus last year; number of at-risk assessments completed; departmental improvements related to quality checks completed in the kitchen; or a lower of food cost due to a decrease in a supplement use. 1. Have the monthly admissions increased and the length of stay decreased? 2. Has the stability of the residents been changing with more status change assessments required? 3. How many residents are followed in the nutrition at risk programs? a. Remind administrator of need to document more frequently on these residents. 4. Has the Rehab unit expanded or the amount of rehab admissions increased? 5. Are there more residents requiring nutrition education? 6. Are residents families requiring and wanting more time and attention from the dietitian? 7. Are the residents having more complicated clinical situations, dictating increased need for consultation with nursing about their medical status? 8. Has the increased focus on the importance of sanitation, safe food handling, and dining services resulted in more time needed for the dietitian to work with the dietary department? 9. Is additional observation of staff members who work with dependent diners required, to assure that residents are receiving the nutrition and level of assistance they need? 10. With culture change issues moving forward, will the dietitian have time to be involved with planning of such projects? In general, the following are some important concepts to consider and should help organize your thoughts prior to meeting with the administrator. 1. Explanation of the ADA s Standards of Practice/Standards of Professional Performance (SOP/SOPP) as opposed to the Dietary Managers Association (DMA) Professional Practice Standards of the Certified Dietary Manager (CDM). In addition to the obvious differences in education and qualifications, the potential for survey deficiencies for inadequate RD time (specifically F281 Professional Standards) should be discussed. continued on page 23

23 How to Talk to an Administrator continued from page With additional RD hours allotted, the dietitian will be able to monitor efficacy of nutritional interventions and make changes related to resident response and/or acceptance. Too many times, supplements are continued longer than necessary because the dietitian does not have the available time for adequate follow-up. Discontinuing supplements and other interventions when appropriate, as well as evaluation of alternative nutritional approaches that may be more cost effective will positively affect the bottom line. It will also potentially decrease undesirable weight gain trends. 3. In order to meet the nutritional needs of the residents it is important to have an effective Nutrition at Risk Program for determining and addressing weight trends. This is essential to compliance with state and federal regulations. As the updated interpretive guidelines specify, weight change is either determined to be unavoidable or avoidable. The RD is a valuable member of the clinical team that makes that determination. 4. Increasing RD hours will allow the RD to work more closely with the dietetic technician, registered (DTR), dietary manager and the food service operation assisting with menu development, to incorporate favorite foods into the menu and to decrease food waste; in review of policies & procedures to ensure compliance with current regulations; and in education of Dietary staff. This will certainly create a positive connection with the residents and the dietary department especially with resident satisfaction as an ongoing focus. The dietitian can offer a middle ground to turn an unhappy, disgruntled resident into a satisfied customer. Allowing time for the dietitian to attend resident council or food committee meetings may also be a benefit to the facility. 5. Showing how the RD plays an integral part in achieving positive resident outcomes i.e.: wound healing in a shorter time through utilization of nutritional interventions and greater RD involvement with the interdisciplinary team (participation in wound rounds; regular reassessment of healing; etc). Of course, in addition to cost savings and financial impact, the RD must be able to show the administrator in black and white the amount of time it realistically takes to do the job. DHCC s Adequacy of Consultant Hours worksheet will assist with calculation and demonstration of these numbers. If, after utilizing the above measures and providing factual information, the administrator or owner is unwilling to allocate the amount of RD hours realistically required to perform all resident and department-related tasks, it may be time to evaluate whether the contract is worth the effort and risk to both reputation and license. It might be necessary to give notice and move on to a client who understands the importance of the dietitian s work and contributions to resident care and the success of the facility. FNCE F. Ann Gallagher Award This award is designed to provide financial support to a registered dietitian who is a member of the Dietetics in Health Care Communities DPG. This award is given to a member of DHCC DPG to financially support promoting state or federal legislation to advance the profession of dietetics. Mary Vester-Toews, RD Recipient of the 2010 F. Ann Gallagher Award WINTER 2011 CONNECTIONS - PAGE 23