Making the Most of Mealtime

  • Author Footnotes
    1 Christine Kilgore is a Frontline Medical News freelance writer based in Falls Church, VA.
    Christine Kilgore
    1 Christine Kilgore is a Frontline Medical News freelance writer based in Falls Church, VA.
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  • Author Footnotes
    1 Christine Kilgore is a Frontline Medical News freelance writer based in Falls Church, VA.
      Last fall, staff leaders at the Maria Joseph Center in Dayton, OH, launched a nutritional experiment. Residents with early and advanced ­dementia began receiving warm fragrant towels upon arrival for their noon meal, followed by 2- to-3-ounce cups of a ­nutrient-dense soup. The arrival was now an activity – an engaging and nourishing process that administrators thought might stimulate residents’ senses of smell and taste and trigger their appetites.
      At the simplest, but perhaps most important level, the results spoke indubitably: “Our weights have stabilized, and we've been able to reduce some of our supplement use on those [dementia] units,” said Suzanne C. Cryst, RD, CSG, LD, director of nutrition services and activities at the not-for-profit 298-bed facility. “We expanded it to dinner as well as the noontime meal, and now we're going to move it on to other units.”
      Weight loss and malnutrition are common problems in long-term care, and are caused primarily by poor food and fluid intake. “We know from countless studies that, consistently, more than half of long-term care residents are at risk of malnutrition,” said Sandra Simmons, PhD, of the Vanderbilt Center for Quality Aging. “The most common statistic is that two-thirds are at risk.”
      The consequences of unintentional weight loss also are well-understood: declines in function and cognition, and increases in infections, falls, pressure ulcers, hospital admissions, and deaths.
      In one study of 900 nursing home residents from 96 LTC facilities, those who lost 5% or more of their body weight in any month – almost half of the participants – had a 10-fold increased risk of death compared with those who gained weight (J Gerontol A Biol Sci Med Sci 2004;59:M633).
      Improving food and fluid intake can seem like an uphill battle, given the natural effects of the aging process itself, the medical instability and comorbidities common among residents, and the resource constraints of nursing homes. And although a body of research on the topic is growing – as with many other facets of long-term care – studies are still laden with imperfections and not reliably translational to practice.
      Even so, leaders in nursing homes and researchers focused on nutrition in the long-term care setting believe there are big gains to be made – if the changes made in nursing homes, such as those made at the Maria Joseph Center, involve multilevel interventions targeting various determinants of food intake and nutrition.
      “There appear to be three key areas – the mealtime experience, meal quality, and meal access – and the thinking is that if we don't look at these three issues together, we're probably not going to significantly improve food intake in long-term care,” said Hilary Dunn. Ms. Dunn is project officer for the Schlegel-UW Research Institute for Aging at the University of Waterloo in Ontario, Canada, which sponsored an international conference this year on improving nutrition for older adults. “We need to reach into each bucket,” she said.
      Increasingly, these ideas are being applied to snack time as well. Snacks and between-meal fluids are no longer just being dropped off to residents, but instead are being presented attractively; residents are offered a choice and individualized assistance as necessary.
      “Unfortunately, our understanding of why inadequate food intake occurs in LTC is fragmented …” wrote Heather Keller, RD, PhD, research chair of the institute in Ontario, in a recent editorial (JAMDA 2014;15:158-61). Still, enough research has been done to know that “poor food and fluid intake is a common but preventable problem in long-term care.”

      Observation, Feeding Assistance

      As a first step to prevent weight loss, treatable causes of poor food and fluid intake must be considered and addressed. These range from depression (believed to be the most common) and chronic infections to various medications, swallowing disorders, oral pain, and other problems.
      Weight loss is one of the best indicators of nutritional risk – and an important cue to investigate such causes. Unfortunately, “weights are notoriously inaccurate” in nursing homes, said John Morley, MB, BCh, director of the division of geriatric medicine at the St. Louis School of Medicine. Studies also have shown common inaccuracies in chart documentation of food and fluid intake, feeding assistance, and other aspects of nutritional status.
      Such issues speak to the importance of carefully observing nursing home residents at mealtime, Dr. Morley and others suggest. Direct observation of food consumption and the mealtime process enables staff to identify residents who consume less than 50% of the food and fluid on their meal trays and are thus at significantly higher risk for weight loss.
      Observation also enables detection of those who need help with posture and positioning, more stimulation or cuing, supportive devices such as plate guards or large-handled utensils, or adjustments in food consistency that make food safe but also as appetizing as possible. (“It may be better,” Dr. Morley noted, “to aspirate a little bit and eat more.”)
      “If we can really work the dining room and make rounds, we can save residents a lot of pain by catching problems and figuring out solutions at the front end,” said Karman Meyer, RDN, LDN, who served for several years as the full-time registered dietician and food service director at Cumberland Manor Nursing Center in Nashville, TN.
      Controlled intervention studies have shown that feeding assistance can have a significant impact on caloric intake, hydration, and body weight. However, the type and extent of feeding assistance required to make a difference are often too time-consuming for nursing staff. It's no wonder, Dr. Morley said, that “many attempts at assisted feeding don't work so well.”
      Dr. Simmons has studied the issue for years, bringing trained research personnel into nursing homes to oversee feeding assistance and measuring the impacts (J Gerontol A Biol Sci Med Sci 2001;56:M790-4; J Gerontol A Biol Sci Med Sci 2004;59:966-73, J Am Geriatr Soc 2008;56:1466-73).
      Her research has shown that 40%-50% of residents who are identified as eating and drinking poorly will significantly increase their intake in response to 30-45 minutes per meal of quality one-on-one mealtime assistance. Usual nursing home assistance averages 6 minutes, Dr. Simmons has reported previously.
      The other 50%-60% of at-risk residents – those who don't respond to mealtime assistance – will increase their intake in response to between-meal snack assistance requiring an average of 12 minutes per snack, compared with usual nursing home care averaging 1 minute of assistance.
      “When you combine these two approaches, you can effectively improve daily food and fluid intake for 80%-90% of nutritionally at-risk residents,” said Dr. Simmons, associate professor of medicine at the Vanderbilt University Medical Center and the Institute for Medicine and Public Health. “For the overwhelming majority of at-risk residents, one of these two approaches – mealtime assistance or snack time assistance – works well.”
      In her more recent study of feeding assistance, published in 2008, Dr. Simmons documented not only improved oral intake but improved body mass index and weight (the earlier studies had looked only at intake). The study was a crossover controlled trial with a 24-week intervention (assistance twice per day during or between meals) and a 24-week control period. Overall, 56% of participants maintained or gained weight during the intervention phase, compared with 28% during the control phase (J Am Geriatr Soc 2008;56:1466-73).
      More than half of the participants in this study were responsive to both interventions, but interestingly, between-meal snack delivery and assistance resulted in more caloric gain than meal assistance for many of these participants. This finding, combined with the fact that snack delivery and assistance requires significantly less time, makes snack time assistance more practical for nursing homes to implement, Dr. Simmons said.
      Still, mealtimes are important. Dr. Simmons’ research and the studies of others have demonstrated that once individual residents are shown to be responsive to feeding assistance, such help can be effectively provided in small groups.
      “One [resident in a group] might need full food-to-mouth feeding, another might be capable of feeding himself, but is easily distracted and needs verbal cues and reminders, and another might need simple help – cutting things up, making sure things are accessible,” Dr. Simmons said. “One staff person can be physically helping one resident to eat, but also doing important things for the other two people to keep them engaged and focused on their food.”
      Dr. Morley said he has seen such small groups working well in nursing homes. “It's not at all an unreasonable approach,” he said, adding that semicircular tables provide an ideal set-up.
      Contrary to what nursing home staff might expect, research has shown that residents who have more severe cognitive impairment are more likely to be responsive to feeding assistance. “These are precisely the people who need it the most and for whom it works best,” said Dr. Simmons, who has also completed two assessments of the Centers for Medicare & Medicaid Services Dining Assistants program (see “An All-Hands-on-Deck Approach to Mealtime”). “Feeding assistance is like any other behavioral intervention,” she added. “The best way to figure out if it will work is to try it.”

      Snacks, Supplements, and Hospitality

      For years, nursing home staff have organized ice cream socials, distributed Popsicles in the evenings, and otherwise made efforts outside of mealtime to give residents extra nourishment and hydration.
      Increasingly, nursing home staff today are incorporating creative snacks into organized social activities and routinely traversing the halls with well-stocked snack carts that are attractive and engaging. Also, staff more frequently assist residents with their snacks and fluids – in sync with what Dr. Simmons has found to be an effective nutritional intervention.
      The new Pioneer Network/CMS New Dining Practice Standards recommend providing residents with more dietary choice and fewer restrictions, and experts say snacks are no exception.
      “We've stopped writing everyone's names on their snacks,” said Ms. Cryst, who began advocating for diet liberalization more than 30 years ago. “Residents need choice and variety, and for those who do need some restrictions, we try to help them make decisions vs. telling them what to do.”
      The issue of supplementation, on the other hand, is far from clear-cut. Oral liquid supplements, the most common type, are no longer given with meals in most nursing homes, as was common in the past. But aside from the use of small amounts of liquid supplements given with medication passes – a now common practice – it is unclear what exactly constitutes best practice.
      Some data show that residents who consume a liquid supplement between meals will eat more at their next meal, Dr. Morley said. But in general, according to experts who spoke with Caring for the Ages, there is too much reliance on supplements in nursing homes, and food should come first.
      “Supplementation is still the most common nutritional intervention you see in long-term care, but for the long term, it shouldn't be,” said Dr. Simmons, who is currently leading an Agency for Healthcare Research and Quality-funded randomized controlled trial to examine the cost-effectiveness of supplements for weight loss prevention in long-term care. When supplementation is used, she added, residents should be offered a variety of flavors and types for optimal intake and less waste.
      “There's a time and place for supplements,” Ms. Cryst said. “I don't think we'll ever get away from it because of the unique needs of our population, but we need to [be thoughtful about it]. It should be driven by a nutritional assessment that looks at [whether the resident needs supplementation], and then whether the resident needs more calories and protein, or mainly more protein.”
      Questions that remain about supplementation stem partly from an incomplete knowledge of the nutritional needs and requirements of the elderly. The elderly generally need more protein than is called for by the current recommended daily allowance (RDA) for adults, yet there is no consensus on how the need for dietary protein changes with age (see “The Power of Protein”).
      In the meantime, the “food first” maxim needs to be accompanied by another rule of thumb – to maximize every bite. Nursing homes making progress on the nutritional front are stepping outside of traditional menu rotations and making super cereals and super puddings, for instance, with higher-fat dairy products and other ingredients that are more nutritionally dense, Ms. Cryst said.
      They are paying more attention to the bigger picture – to food presentation, dining environment, and other aspects of the eating experience that are homelike and dignified and that counter the natural effects of aging that can contribute to weight loss and malnutrition, such as impairments in smell and taste and a decline in the underlying drive to eat and drink.
      “Nursing homes all over are dealing with the same issues when it comes to the challenges of improving food and fluid intake,” said Dr. Simmons. “This really speaks to the power of identifying efficacious interventions.”
      Merijane McTalley, RND, envisions dieticians working hand-in-hand with physical therapists. Based on where the science is moving, “there has to be a lot more interdisciplinary teamwork to help residents build muscle strength,” said the dietician, who founded Nutrition Ink, in Banning, CA, more than 30 years ago.
      For now, protein intake should increase, according to a recently published position paper from the PROT-AGE Study Group, an international study group charged with reviewing dietary protein needs for the aging. The group, which includes Dr. Morley, recommends that average daily protein intake be increased from 0.8 g/kg of body weight to 1.1-1.2 g/kg of body weight per day. Older individuals with severe kidney disease are an exception. However, the study group says evidence is not yet sufficient to support specific recommendations regarding protein quality, the timing of ingestion, or intake of other supplements.
      The Power of Protein
      Merijane McTalley, RDN, who founded and leads a consulting firm that provides dieticians and dietary services to long-term care facilities, has believed for some time that the elderly need more protein than what the national guidelines recommend.
      There's something changing, however, that Ms. McTalley is paying close attention to as she reads the literature and attends nutritional seminars. “There's more attention being paid to protein intake and what's being called ‘sarcopenia,’ and a lot of discussion about how the loss of [skeletal] muscle mass has more to do with malnutrition than anything else,” she said.
      Indeed, according to a 2009 review on dietary protein and the prevention of sarcopenia, or muscle wasting, “much of the recent commentary has argued that the current RDA for protein … does not promote optimal health or protect elders from sarcopenic muscle loss” (Curr Opin Clin Nutr Metab Care 2009;12:86-90).
      The amino acid leucine is getting increasing attention. Recent studies in both animals and humans suggest that supplemental leucine may help improve or normalize protein synthesis in aging muscle, the reviewers noted.
      John Morley, MB, BCh, director of the division of geriatric medicine at the St. Louis School of Medicine, said supplementation with leucine-enriched essential amino acids may indeed be a nursing home best practice of the future, along with improved attention to exercise.
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      Some nursing homes are finding success in their nutritional programs by emphasizing more nutritionally dense foods and creating a more homelike dining experience.
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