Thursday, June 15, 2023

 Tracking Functional Status

There is ample research in the field of geriatrics and dementia which has produced accredited studies detailing measurable outcomes from assessment tools designed to quantify characteristics of persons suffering from dementia in the areas of depression, cognition, nutrition, behaviour and even happiness. Using these tools to create baseline assessment and measure changes in condition will enable providers, families and primary care professionals to measure and understand the disease progression and determine the best course of treatment for these residents that will enable them to achieve the highest possible functional status and quality of life.

            Assessment Tools

·       The Mini–Mental State Examination (MMSE) or Folstein test is a 30-point questionnaire that is used extensively in clinical and research settings to measure cognitive impairment. It is commonly used inmedicine and allied health to screen for dementia It is also used to estimate the severity and progression of cognitive impairment and to follow the course of cognitive changes in an individual over time; thus making it an effective way to document an individual's response to treatment.

·       The Geriatric Depression Scale (GDS) is a 30-item self-report assessment used to identify depression in the elderly. In the Geriatric Depression Scale, questions are answered "yes" or "no." A five-category response set is not utilized in order to ensure that the scale is simple enough to be used when testing ill or moderately cognitively impaired individuals, for whom a more complex set of answers may be confusing, or lead to inaccurate recording of responses.

·       The Cornell Scale for Depression in Dementia (CSDD) is a way to screen for symptoms of depression in someone who has dementia. Unlike other scales and screens for depression, the CSDD takes into account additional signs of depression that might not be clearly verbalized by a person. For example, if your loved one or patient has Alzheimer's diseasevascular dementia or other kind of cognitive impairment, he might not consistently be able to accurately express his feelings. The Cornell Scale measures observations and physical signs that could indicate depression.

·       The Morse Fall Scale (MFS) is a rapid and simple method of assessing a patient’s likelihood of falling. A large majority of nurses (82.9%) rate the scale as “quick and easy to use,” and 54% estimated that it took less than 3 minutes to rate a patient. It consists of six variables that are quick and easy to score, and it has been shown to have predictive validity and interrater reliability. The MFS is used widely in acute care settings, both in the hospital and long term care inpatient settings.

·       The Comprehensive Geriatric Assessment (CGA) - The geriatric assessment is a multidimensional, multidisciplinary assessment designed to evaluate an older person's functional ability, physical health, cognition and mental health, and socioenvironmental circumstances. It is usually initiated when the physician identifies a potential problem. Specific elements of physical health that are evaluated include nutrition, vision, hearing, fecal and urinary continence, and balance. The geriatric assessment aids in the diagnosis of medical conditions; development of treatment and follow-up plans; coordination of management of care; and evaluation of long-term care needs and optimal placement. The geriatric assessment differs from a standard medical evaluation by including nonmedical domains; by emphasizing functional capacity and quality of life; and, often, by incorporating a multidisciplinary team. It usually yields a more complete and relevant list of medical problems, functional problems, and psychosocial issues.

·       The Mini Nutritional Assessment - The Mini Nutritional Assessment is an effective, easily administered tool designed to identify older adults who have or are at risk for developing malnutrition. It consists of 18 questions and can be completed in about 15 minutes. A short form, containing the first six questions, can be used for screening.

·       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.

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.