Thursday, February 20, 2020

Frequency and Indicators of Malnutrition in the Elderly

Anorexia is an overall decline in appetite leading to decreased food intake, and consumption of inadequate calories. It is the major cause of weight loss and poor nutritional status in elderly persons[i].  Malnutrition and dehydration are associated with susceptibility to infections, cognitive impairment, poor skin and bone integrity, pressure sores and hip fractures. These serious consequences along with co-morbidities from chronic illness, often lead to mortality[ii].  A protocol to screen and assess elderly residents for nutritional risk is essential in establishing early interventions to diminish serious health effects of malnutrition.  

A research group called the Collaborative Studies of Long Term Care, initiated in 1997 a series of multi-state projects that studied almost 5,000 residents in more than 350 retirement and assisted living communities published their findings in a special issue of the Gerontologist.[iii]  Findings showed that low food intake was common in 54% of the participants and low fluid intake is prevalent among 51% of those studied in Long Term Care, particularly those with cognitive impairment. They found that residents who were closely monitored by staff during meal times are significantly less likely to have low food and fluid intake.  Similarly, residents who eat their meals in a central dining area are much less likely to have low intake than those dining in their bedrooms.  Often, in large facilities meal times are set and residents have limited time to consume their food.  Pressured with time limits, staff can mistakenly assume that the resident is not hungry and removes much of the uneaten food before the resident is able to finish.

Physical examination can point to clear, visible signs of weight loss.  Pronounced indentations at the temporal lobes commonly referred to as temporal wasting, loss of muscle mass, loose elastic skin, and decreased functional ability to perform activities of daily living (ADL’s) are all early indicators. Causes of weight loss are numerous and can include: swallowing difficulties, poor dentition, mouth pain, psychological disorders, depression, impaired mobility, and loss of appetite. Residents who begin to lose 5% of their weight in one month, or 10% over 6 months, or those who eat less than 75% of their food at meal times should be considered for a complete nutritional evaluation by a Registered Dietitian.  

Operators should routinely evaluate body weight at the time of admission, and monthly thereafter. Use of the Body Mass Index[iv] (BMI) can help establish a baseline, and subsequent measures can point to clear trends of weight maintenance or decline. Residents who are determined to be high risk for weight loss can be identified in their chart and with a silicon bracelet.  Staff will then notify and involve a registered dietitian who intervenes with an individualized food plan.  Angela G. Sullivan MS RD consultant dietitian for Potomac Homes suggests, “The specific nutritional recommendations we make are in addition to a liberalized menu, offering favorite foods, and routine mealtime practices”.  “The strategies and protocols for the resident at risk address prevention of continued weight loss and dehydration.” The emphasis is to make sure food and fluid are optimized at each meal, snack and hydration opportunity[v].  “Simply adding supplements is not enough to prevent weight loss”, she warned. Recommendations might include adequate texture changes for residents who have difficulty swallowing. Cutting up food, adding sauces and gravy to add extra moisture, and delaying the need to puree food are all strategies that focus on taste and appearance, and address quality of life. “Allowing residents additional time to complete their meal, offering assistance with feeding, using words of encouragement in addition to nutritional supplements and calorie dense snacks are protocols that can really make a difference,” She concludes.

Researchers followed weight loss trends of 1000 nursing home residents across the United States.  They found many of elderly residents to be undernourished. During a six month period, 30% of those residents who continued to lose weight died.  The study also found that 16-18% of elderly living in communities consume less than 1000 calories per day.

Clearly elderly that are at risk for weight loss who are treated with additional emphasis during meal times and throughout the day can greatly benefit, even avoid the early onset of nutritionally triggered catastrophic health failures.  By recognizing at-risk residents early, operators can have a significant impact on the overall quality of life of their residents and help manage the acuity of care in their homes.

[i] Thomas, D.R., MD, Morley, J.E. Regulation of appetite in older adults. Clinical Strategies in LTC, a Supplement to Annals of Long-Term Care.  July, 2002.  Page 4.

[ii] Thomas, D.R. Progress Notes: Nutrition and Chronic Wounds. Supplement to Annals of Long-Term Care.  November, 2004. Page 1-12.

[iii] Reed, Peter S., Zimmerman, Sheryl, Sloane, Philip, Williams, Christianna, and Boustani, Malaz. Characteristics Associated with Low Food Intake in Long-Term care residents with Dementia. The Gerontologist. Vol. 45 . October 2005. Page 74-80.

[iv] BMI uses a mathematical formula that takes into account both a person's height and weight. BMI equals a person's weight in kilograms divided by height in meters squared. (BMI=weight
 kg/height m2). Mahan K. L., Escott-Stump S., Food Nutrition & Diet Therapy, 9th edition, Saunders., 1996, Appendix 18 pg 950-951

[v] Liberalization of the Diet Prescription Improves Quality of Life for Older Adults in Long-Term Care. Journal of the American Dietetic Association. Volume 105, Issue 12, December 2005, Pages 1955-1965.

Chemosensory changes in the Aging Process: Mom seems to be losing her appetite

Most people understand that as we age, the way in which we experience our world through our senses of sight, hearing, touch, taste, and smell changes as those senses deteriorate over time. As our visual acuity diminishes, we wear corrective lenses; with auditory loss, we wear hearing aids. However, the least accepted and least understood deprivations are those of taste and smell, the two senses that primarily control the body’s ability to experience food. Disorders of taste and smell are viewed as affecting the “lower” senses—those involved with sensual and emotional life—rather than the “higher” senses that serve the intellect.

The taste and smell of food have a major effect on levels of food intake and the maintenance of good nutrition. Losses and distortions in these chemosensory mechanisms contribute to a significant degree to anorexia in the elderly. Taste and smell are considered chemical senses because molecules that contact receptors in the mouth, throat, and nasal cavity stimulate them. The sense of taste is mediated by taste buds located on the dorsal surface of the tongue and on the epiglottis, the larynx, and the first third of the esophagus. Olfactory receptors are bipolar neurons located in the upper portion of the nasal cavity that project into the limbic system of the brain. The limbic system also processes information associated with emotions, so there is, in fact, a medical explanation for the emotional response we have to food. The olfactory bulb shows considerable degenerative changes during aging, and cross-sections of the bulb often look “moth-eaten” owing to losses in the number of cell bodies of neurons. Those losses are especially profound in patients with Alzheimer’s disease.

Because of reduced function in these key chemosensory systems, the natural biochemical responses designed to break down food as it enters the body are consequently also less active. When the body smells, tastes, or simply sees appetizing food, a number of biochemical responses are set in motion to aid subsequent digestion. For example, saliva builds up in the mouth, gastrointestinal juices are released into the stomach, plasma insulin is released into the bloodstream, and the pancreatic system is engaged. All these responses have the combined effect of aiding absorption of food and promoting overall nutrition. As the aging process affects the body’s internal response to food, seniors do not enjoy food as much or absorb it as well, and as a result they can become vulnerable to malnutrition, which can contribute further to health problems.

Taste and smell decrements arise not only from the normal aging process, but also from certain disease states, pharmacological and surgical interventions, the effects of radiation, and environmental exposure. Similar medical conditions and drugs affect the sense of smell. For example, most people have experienced the metallic taste of orange juice after brushing their teeth; the chemical in toothpaste responsible for this effect is sodium lauryl sulfate, which is also used to help fat-soluble drugs dissolve. Most elderly persons take their medications with their meals to offset the potentially harmful effects of the drugs on the stomach lining, which in turn affects their ability to taste and smell their food. Their senses are inhibited by these drugs, as is their digestive system, and this effect can at times induce a negative reaction and in severe cases lead to malnutrition.

Many medications commonly prescribed are recommended to be taken with food. Often people will take their medications before they eat, especially when dinner plans call for a night out to a restaurant. By the time their meals actually arrive at the table 60 minutes or more could have passed since they consumed the medication prior to leaving home, giving the medication taken on an empty stomach ample time to be absorbed into the bloodstream and the opportunity to adversely affect their ability to taste and smell their food. Simply advising people to take their medications after they eat rather than before can have a profound effect on their overall dining satisfaction. In fact, at one senior living community, after the seniors were educated about this concept, senior satisfaction in food and beverage service increased by 10 percent over the previous survey, while perceptions of all other conditions remained constant[i].

Measurements of taste and smell dysfunction in adults reveal a progressive decline with age. Those losses tend to begin around 60 years of age and become more severe in persons over 70 years of age. In most retirement communities, the chef and cooking staff have an ability to taste and smell that is more than twice as acute as that of the people for whom they are cooking. In one study, persons between the ages of 20 and 70 had approximately 206 taste buds each. This number was reduced to 88 taste buds for persons between the ages of 74 and 88 years.  The average age of seniors in retirement communities today is about 82 years. Therefore even the best-qualified chefs working with the freshest natural ingredients are working at a considerable disadvantage, and they will express their frustration in trying to address this problem using conventional methods. Seniors may inadvertently harm themselves by trying to amplify the flavors of their food by using too much salt at the table, or by eating too much dessert because they can still enjoy the sweet taste of many of these offerings. Compensating in these ways, however, only leads to nutritional imbalances and could be in direct conflict with doctor-prescribed dietary guidelines.

Recent studies suggest that the amplification of foods and beverages with naturally produced flavors can increase preference ratings as well as subsequent intake and absorption in elderly persons with known chemosensory losses. These commercially produced flavor enhancers, which are inexpensive (adding less than a penny to the per-meal cost), are made by reducing food such as chicken and capturing and concentrating natural flavor and odor molecules. The concentrate can then be attached to a “carrier” (such as water, oil, or flour) and added to the food. This added flavor contains no fat, salt, or other harmful products traditionally associated with flavor enhancement.

Flavor-amplified foods not only are preferred from a sensory standpoint, but also can influence the body’s natural biochemical response to food, actually promoting better absorption and, as a result, improving the immune status of elderly persons. In a study by Schiffman and Warwick, elderly persons were offered regular food for three weeks, then flavor-enhanced versions of the same food[ii]. Blood samples were taken before and after the use of the flavor enhancement. They showed an increase in levels of T and B cells (white blood cells), the body’s natural defense agents against disease and injury.  Schiffman’s research confirms that as the body’s biochemical absorption of food improves, so do nutrition and immune status. This research suggests that the addition to recipes of natural flavors that increase the perceived flavor intensity would improve satisfaction with the food and compensate for chemosensory losses due to normal aging, diseases, and prescription drugs. It can be argued that the use of flavor enhancements can actually promote better health as well as improve culinary satisfaction.

The increased preference for flavor-enhanced food is extraordinary. In fact, many manufacturers of convenience products, such as Stouffers and Tyson, now list natural flavors among their ingredients. When a convenience product and its scratch-made counterpart are served, the convenience product is often better received than the homemade one. This is simply because the commercial product is higher in flavor than the homemade product as a result of added natural flavor. Certainly natural products are important and should represent the primary ingredient source. The addition of fresh herbs and spices and pre-treating with marinades should not be abandoned. We walk a fine line, however: for if too many herbs and spices are added, the seasoning then overpowers the main ingredients. Often seniors’ delicate digestive systems become agitated when aromatic herbs and spices are not used in moderation.

Research has confirmed an improved immune status as measured by the total level of blood lymphocytes, which help to fight diseases inherent in the elderly population. In addition, seniors feel better about their dining experience, and opioid (endorphin) levels increase as seniors’ ability to sense their food improves. It has actually been proven that seniors become physically stronger as well. With flavor enhancement, seniors are less interested in fatty foods and in adding salt to their entrees, and thus they are better able to adhere to their doctor-prescribed dietary guidelines.

[i] Benjamin W. Pearce, Reactivating Appetite, Eldercare Advisor Press, Amazon Kindle eBook, Amazon Digital Services (2014).
[ii] S. S. Schiffman and Z. S. Warwick, "Effects of Flavor Enhancement of Foods for the Elderly on Nutritional Status: Food Intake, Biochemical Indices, and Anthropometric Measures," Physiology and Behavior 53 (1992): 395-402.

Intervention Series: Mom seems to be losing her cognition - what you can do

Cognitive Interventions

Cognitive interventions must be blended with a perspective allows us to understand a person not only as someone who suffers from illness or unhealthy conditions, but also as someone who inhabits healthy parts and personality that remains even though it seems to be hidden by illness .  For staff and families, engaging the person behind the impairment will allow everyone to feel good about participating with the residents in the activity experience. 

Alternatives for Cognitive Intervention:

A therapeutic, multi-faceted interdisciplinary approach to activities, social and leisure programming provides specialized stimulation to create structure and support in meeting the physical, psychosocial, cognitive and spiritual needs of each participant. This is especially important for people who are confined in a locked unit and unable to freely experience the outside world where most of the rest of us readily access a wide array of activities and stimulation during the course of our everyday lives. The best practices components listed below allows providers to focus on residents' wellness and their holistic needs, rather than the losses the disease causes. The following research-based programming should then be scheduled to align therapeutic activities with common dementia behaviors as they typically occur during the day. This provides stimulation within each resident's capabilities that is failure-free and success oriented, at specific times when they are most likely to respond favourably.
Failure-Free - Activities that encourage participation at any functioning level, from low functioning to high functioning while still building self esteem of the participants. Participants are not at risk in these activities of being singled out or embarrassed. (Recommended frequency = Daily).
Exercise - Seniors with dementia tend to be less careful ambulating than their non-demented counterparts who are constantly aware of and fear the consequences of a fall. Unfortunately seniors suffering from dementia are at a significantly higher risk for falling than the general elderly population. Morning exercises and physical activities at least every two hours throughout the day keep joints limber and reduce the frequency of devastating falls. Elderly people need to support their own weight and/or walk at least every two hours. This helps them to maintain body strength and muscle mass while improving their coordination, circulation and avoid pressure sores. Elderly can also experience dizziness when standing up.  This is caused by blood pooling in their lower extremities (orthostatic hypotension). It is vital to let them stabilize on their feet for a minute after they have been sitting, or lying for an extended period to prevent dizziness and a potential fall. (Recommended frequency = Daily).
Grooming - Residents who are well groomed feel better about appearing in public than those who do not dress appropriately and groom for their day. People with dementia are at risk of remaining in their rooms in bedclothes without grooming are more at risk for isolation and vulnerable to depression. (Recommended frequency = Daily).
 Current Events - It is important to provide residents a window on the world and keep them informed regarding top stories in the news. This connects them to important events outside their senior living community and stimulates them to maintain cognition. (Recommended frequency = Daily).
Reminiscence - This is the act or process of recollecting past experiences or events. Programs such as trivia, finish the phrase, memories that relate to holidays or the current month, or taking them back to "the Good old days" can help to connect them to their past and ease the fears they experience daily in failing to remember people, places and things. (Recommended frequency = Daily).
Long-Term Memory - These are memories that many people hold onto until late in their disease progression.  These are activities that encourage working with familiar life-long tasks of everyday living such as sorting laundry, setting a table, winding yarn, reminding them what they did in their life, by cueing and using memory stations, and encouraging interaction with these familiar items. Programs that cue residents to access their long-term memories can highlight to them what they can still do which builds self-esteem and confidence. (Recommended frequency = Daily).
Short-Term Memory - These are memories in the immediate past present of days or weeks. Normally the first symptom noticed by families. Programs that offer structure, a calendar or written daily agenda, note cards to refer to. Using familiar photos, family albums, pictures of favorite foods or activities recently completed can help build confidence and reduce fear and anxiety. (Recommended frequency = Daily).
Cognitive Stimulation - This is the intervention that offers a range of enjoyable activities providing general stimulation for thinking, concentration and memory, normally in a small social group setting. It is aimed at general enhancement of cognitive and social functioning. These activities include word games, puzzles, music and practical activities like baking or indoor gardening. All activities were designed to stimulate thinking and memory. Improvements for participants following cognitive stimulation show a much higher functional status. (Recommended frequency = Daily).
Psychosocial - Synaptic reserve, neuroplasticity, and perhaps other factors such as neurotransmission, and neurogenesis may be impacted by lifetime intellectual achievement.  The relationship of leisure activities or other forms of intellectual stimulation such as social interactions to diminished risk for dementia suggests several mechanisms including stress reduction and overall cognitive stimulation are at play. Offering stimulation that reaches back to life-long love and work for others, helps to reflect on the past and validate the present. Creating activities surrounding lifetime accomplishments, travel destinations and other bucket list accomplishments gives a sense of life purpose to participants. (Recommended frequency = Weekly).
Eye-Hand Coordination - Exercising the participant's creativity and fine motor skills can help build a sense of accomplishment. The more you build upon remaining abilities the higher the quality of life they will enjoy. (Recommended frequency = Weekly).
Socialization - Humans are social creatures, but as people begin to lose their memory and become aware of their losses, they tend to seek isolation to avoid embarrassment and confrontation. Programs designed to be delivered in small groups will enable each participant to offer what they can without being singled-out. Programs such as a group exercise activity (parachute) or finish the phrase or wheel of fortune all offer a venue for socialization with other residents while allowing them to express themselves within their individual comfort zone. (Recommended frequency = Daily).
Arts and Crafts - These activities can build self confidence and offer a sense of accomplishment. Creating a door hanger or artwork each month is fun and helps to build self-confidence. Higher functioning residents who help lower functioning residents with their art projects feel a sense of pride and contribution. Assisting others helps to overcome their own insecurities. Art therapy also helps to restore brain synapses through eye-hand coordination. (Recommended frequency = Weekly).
Multimedia Interaction - Researchers surveyed people with dementia and reported that travel and engaging with nature and science were most important to them in terms of their quality of life. Surveying families can help identify life-long interests such as travel, nature, sports, ancient history, oceans, cooking or science.  PBS or Nature series programs available to download from the internet and a great commercial-free way for people to access this. Programming exposure to these themes helps participants remain connected with their passions. (Recommended frequency = Daily).
Sing-a-long - Many people with long-term memory remaining will respond well to sing-a-long programs and music therapy where they can participate at will and often surprise themselves with how well they remember popular songs of their younger days. Music bingo, holiday sing-a-longs and other singing games offer a great social and confidence building venue to residents to access past fond memories. (Recommended frequency = Weekly).
Spiritual and Religious - Remaining active spiritually is very important for elderly people who tend to become more religious later in life. A balanced program which offers interdenominational services or even religion specific services can help residents remain connected with their faith. At the heart of our being exists a core set of virtues – gifts that represent the essence of the human spirit and the content of our character. These gifts are universal, not defined or limited by gender, nation, race or religion. They are inherent in the human experience.  Research shows that seniors need to keep in touch with their spiritual self to live life fully. Living virtues provide empowering strategies that inspire the practice of virtues in everyday life through simplicity which support our residents to cultivate their virtues – the gifts of character. (Recommended frequency = Weekly).
Low-Functioning - Sensory stimulation is needed for even the lowest functioning participants to offer distraction and engagement. Programs that offer simple exposure to stimulate participant's sense of touch, taste, smell, site and hearing can provide engagement and reach into the spirit of someone who may be otherwise catatonic. In many cases it is impossible to tell if a participant is responding mentally to these stimuli, but research has shown that many people with advanced dementia are engaged by sensory stimulation even though they may be unable to physically respond to it. Bubble painting, name that smell, feels like, sounds like, tastes like, or edible art like Hello with Jell-o can all bring stimulation and quality to life. (Recommended frequency = Daily).
Sequencing - Sequencing and muscle memory are among the last cognitive skills to erode for a dementia patient. Sorting silverware, folding napkins, word-find, or playing with musical instruments can restore confidence that participants can still access those skills and be successful in manipulating their form and function. (Recommended frequency = Weekly).
Non-verbal Communication - much of what we perceive about each other is not what is said by how it is communicated.  Activities designed to have fun with non-verbal cues can offer both verbal and non-verbal participants a fun and engaging experience. Introduce the topic by talking about body language. Define it for them if needed. Tell the residents that you are going to communicate non-verbally with your face and body and ask them to guess your mood. Use Happy (smiling and joyful) Sad (mouth turned down and sorrowful) Afraid, amorous, hurt, and yes confused!  Have fun with it and ask the residents to show you how they look for each of these emotions. (Recommended frequency = Daily).
Behavior Modification - Many residents with dementia also experience anxiety disorder. This is typically manifested in the afternoons and often referred to as "sundowning." Physicians normally treat this disorder with medications from the Benzodiazapine family. For many residents, these medications, while effective, can leave patients depressed, dispirited and even catatonic. There has been ample research with essential oils and auditory artifacts that have offered evidence to moderate behaviors without chemical intervention. Aromatherapy is the art of using essential oils to benefit ones physical, spiritual and psychological well-being. Aromatherapy can provide sensory stimulation or relaxation, increase self-esteem, and work against a sense of self-isolation. It can provide opportunities to communicate non-verbally, and enhance reminiscence, memory retrieval, and mood stabilization. Binural beats or delta tones are very low frequency auditory processing artifacts, or apparent sounds, the perception of which arises in the brain for specific physical stimuli. Delta tones have been used extensively with people who suffer from insomnia to induce relaxation, meditation, creativity and dissimulate the brain activity. Binural beats reportedly influence the brain in more subtle ways through the entertainment of brain waves and have been claimed to reduce anxiety and provide other health benefits such as control over pain. (Recommended frequency = Daily).
Other therapies - Horticultural therapy is an interaction between people and plants. This process has a powerful benefit that gives someone receiving care the opportunity to become a caregiver themselves, as they nurture their plantings. The benefits to a dementia population are many. Not only the physical benefits of utilizing fine and gross motor skills, but also the emotional benefits of working with plants include the sensory and mental stimulation, decreased anxiety, and improved orientation to reality with the stimulation of long-term memories. Pet therapy is another way seniors can stay connected to their past and is for many an opportunity to be the caregiver that is calming to both resident and pet alike. (Recommended frequency = Monthly).
Entertainment - Everyone loves to be entertained, whether its live music, multi-media or audio tracks. Having paid entertainer perform for the residents, or even an open mike night can bring that musical stimulation many people crave and enjoy right into their community. Often school bands, or dance groups can be arranged to come and perform for the residents which can offer the group experience performing before a live audience. Regardless of the source or reason, seniors love to be entertained, it stimulates so many emotions and offers a significant boost in their quality of life that is always enjoyed with eager anticipation. Where words fail, music speaks, its the sound of life. (Recommended frequency = Monthly).
Saint Louis University Mental Status Examination (SLUMS) - a method of screening for Alzheimer's and other kinds of dementia. It was designed as an alternative screening test to the widely used Mini-Mental State Examination (MMSE). The idea was that the MMSE is not as effective at identifying people with very early Alzheimer's symptoms. Sometimes referred to as Mild Cognitive Impairment (MCI) or mild neurocognitive disorder (MNCD), these symptoms occur as people progress from normal aging to early Alzheimer's.
Conduct your own assessment: