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 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 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 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 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

4 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 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

5 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

6 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 health care professionals and administrators to encourage all older adults to dine with others rather than dining alone. Dining Ambiance 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

7 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 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 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

8 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

9 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 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 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 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

10 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