• E-mail
• Print
• Comment
• Font Size
• Digg
• del.icio.us
• Discuss article

Problems With Eating and Nutrition: Geriatric Self-Learning Module

Posted on: Friday, 7 January 2005, 03:00 CST

The Geriatric Resource Nurse Model is used at the University of Virginia to improve the competency of staff in caring for older adults. Eight self-learning educational modules were developed to address common concerns in hospitalized elders. The Problems With Eating and Nutrition: Geriatric Self-Learning Module is published here, along with a post test. This is the second in a four-part publication of self-learning modules.

The Geriatric Resource Nurses at the University of Virginia developed the Self-Learning Modules in Geriatric Care (Lee, Fletcher, Westley, & Fankhauser, 2004). The SPPICEES pneumonic addresses eight distinct modules, each targeting a commonly encountered health concern of older adults across health care settings. These include:

S: Sleep

P: Problems with eating and nutrition

P: Pain

I: Immobility

C: Confusion

E: Elimination

E: Elder abuse

S: Skin

The modules were designed using a case study approach in order to encourage the learner to gain new knowledge as well as apply this knowledge. Each module includes two case studies, one applicable to the care of an older adult in the inpatient setting and the other applicable to an older adult in the outpatient setting. Each module will take approximately 20 to 30 minutes to complete.

The completion of these self-study modules alone does not ensure the staff member is age-specific competent; this is determined through the observation and demonstration of behaviors while working directly with older adults. However, these modules will enhance the staff member's knowledge as a foundational step in developing competent behaviors.

Purpose

The purpose of this module is to provide age-specific educational information related to nutritional problems in older adults for the inpatient and outpatient staff.

Target Audience

This self-study module is for use by health care professionals caring for older adult inpatients and outpatients.

Directions

1. Read and review the learning objectives.

2. Read both case studies and the self-study module information.

3. Answer the post-test questions.

Objectives

At the conclusion of this module the professional patient care staff will be able to:

* Discuss reasons why the risk of poor nutrition is increased in older persons.

* Identify cues that indicate a need for more in-depth assessment.

* Discuss interventions that help address nutrition problems.

Overview

The food pyramid continues to be a good basic guide for a healthy diet as people age. Recent changes to the recommended daily allowances address those over age 50 for the first time. Nutrient needs tend to increase as people age, although their caloric needs generally do not increase because of diminished activity and decreased metabolism. If extra weight is a health concern, the older adult needs to eat nutritionally dense food to get more nutrients in fewer calories than a younger counterpart; this is often a challenge. However, the opposite problem of weight loss and protein calorie malnutrition is extremely common in elders, particularly among the sick and hospitalized. Inadequate fluid intake is also very prevalent. Because older adults have a diminished sense of thirst, they often drink less but still usually need approximately 2,000 cc of fluid a day.

Multiple problems and changes occur as people age which make obtaining, eating, enjoying, and metabolizing adequate amounts of food a challenge. By some estimates as many as 25/6 of Americans age 60 and older are malnourished. Nutrition is extremely important to good health, and even subclinical deficiencies can impact body function (Johnson, 1997). Risk factors for poor nutrition in the older adult are typically cumulative and interrelated. A great variety of diverse issues can influence an elder's ability to be nutritionally healthy. A partial list includes the following:

* Normal aging changes in smell and taste.

* Ill-fitting dentures and other oral or dental problems.

* The impact of disease which may change nutritional needs or interfere with adequate intake.

* Depression, confusion, and memory loss.

* The effects of multiple medications.

* Substance abuse (an estimated 10% of elderly abuse alcohol).

* Diminished function which limits ability to shop, cook, and prepare meals.

* Social isolation.

As the number of risk factors increases, the prevalence and degree of impaired nutrition also increase.

Unintentional weight loss of over 10 pounds in 6 months should be investigated. It is often a sign of illness. Many older persons suffer from inadequate food intake and protein energy malnutrition, not only in the community but also in acute and long-term care settings. In these settings, food intake is often inadequate for a variety of reasons. Appetites are poor because of illness, anxiety, medication side effects, lack of physical activity, and/or depression. Tests and studies may require NPO status that is sometimes continued longer than necessary. Patients may be unable to obtain food they find appealing. Negative comments about hospital food are common. The variety, preparation, and presentation of hospital food have definitely improved but it is still a challenge for patients to get food they want, prepared as they would like, at the time they feel like eating, and at the correct temperature. For patients in questionable or poor nutritional health, not eating well has significant implications for energy, wound healing, cognition, and their sense of well-being.

When illness results in significant weight loss, evaluation by a registered dietitian is very important to ensure appropriate interventions and adequate nutritional intake. Speech and occupational therapy evaluation and treatment may also be needed to enable patients to feed themselves and eat safely.

Getting adequate nutrition is also a challenge for many older people who live on their own in the community. After getting help to address their risk factors and obtaining medical attention as appropriate, older patients and families may use a variety of resources to assist with nutritional needs. Examples of these resources are Area Agencies on Aging, Meals on Wheels, nutrition sites, home health agencies, and paid advocacy services. In addition to these formal resources, informal networks of family, friends, neighbors, and church groups often provide assistance that allows older people to remain in their homes.

Outpatient case Study

You work in an outpatient clinic and a receptionist asks your advice about the following situation.

"My 81-year-old father lives alone, about 300 miles away with no other immediate family members close by. He has been caring for himself without a problem but recently when I visited, his clothing looked baggy and there was little food in his refrigerator. He ate well when I was there, but I am concerned about what is going on when I am not. Do you have any suggestions about what I should do?"

What suggestions would you give her? Compare to following discussion.

* Begin by acknowledging her for taking an interest and picking up on some clues that raise questions about her dad's nutritional status. Ill-fitting clothing indicates weight loss that, if unintentional, deserves a closer look. His lack of food is also of concern; however, he seems to have a good appetite and that is a positive finding.

* Suggest that she talk directly with him and express her concerns. Find out if he identifies problems. Does he feel that he has lost weight? It will be easier to address issues if she can work with him as a partner. A good place to start would be to ask if there have been changes in his function and his ability to obtain, prepare, or eat his food. What medications is he taking? Anything new? Have changes occurred in his social network?

* Ask him to keep a record of what he eats for a few clays.

* Does she know his usual weight? Can she weigh him or get him to weigh himself?

* When has he last seen his health care provider? A visit to his primary care provider would be appropriate if he has lost 10 pounds or more in the past 6 months. She might go with him or call and alert the office about her concern prior to his visit.

* Caring for an older adult relative at a distance is a challenge. It is never too early to set up a network of formal (community agencies and service providers) and informal support (friends, neighbors, family members) to help with his care. If she feels she needs additional help, suggest she also call the local caregiver helpline.

* The Area Agency on Aging (AAA) in her father's vicinity can also provide information about home-delivered meal programs, senior centers that provide hot lunches, and any volunteer services that may exist to help with such things as grocery shopping. Also, the Department of Social Services may know of services and resources. To find the number for the Area Agency on Aging in her father's area, she can call Eldercare Locator (1-800-677-1116).

Inpatient case Study

Ms. T.E. is an 88-year-old white female admitted to your unit from the ED. She was admitted because of increased confusion and lethargy. She lives with her 86-year-old sister and was brought into the ED by a concerned niece. T.E. has no known health problems and does not take any medications. Your findings on admission assessment: frail older woman who is oriented to self only. IV fluid is infusing in her left forearm. She is weak and needs maximum assistance to move from the stretcher to t\he bed. Her hair is thin and sparse, and mucus membranes are pale and dry. Vital signs T 97, P 122, R 22, BP 86/60, and weight 102 lbs (50.9 kg).

Additional significant physical findings are

* moderate kyphosis,

* diminished size and tone of the muscles of her extremities,

* poor skin turgor, and

* 1+ to 2+ edema bilaterally in lower extremities.

Significant laboratory data include the following:

* red blood cells (RBC) 3.1 (3.6-5 10^sup 6^)

* hemoglobin 10.5 (12-16 g/dL)

* hematocrit 35% (36% - 48%)

* sodium 148 (136 - 145 mEq/I)

* blood urea nitrogen (BLJN) 50 (8-23 mg/dL)

* creatinine 1.0 (0.6 -1.1 mg/dL)

* albumin 3.1 (3.5-4.8 g/dL)

What data give cues that nutrition and dehydration are significant areas of concern? List these and then compare to the discussion of the case study.

Vital signs. Her elevated pulse rate and her decreased BP likely are related to dehydration. At 102 pounds, she is thin. Given her dehydration, you would expect a weight loss. However, it is important also to consider her nutritional status. She may have been thin all her life, but it is important to get information about her usual weight and any significant recent weight loss. Significant weight loss is considered 5% or more of body weight in 1 month, 10% or more of body weight in 6 months, and/or involuntary weight loss of 10 pounds in 6 months.

Physical exam findings

* The niece reports that T.E.'s weakness, lethargy, and confusion recently have increased. There may be other causes, but dehydration is a contributing factor. Malnutrition would be a factor as well in her baseline lethargy. Possible nutritional causes of her confusion are vitamin B and folate deficiencies.

* Dry mucous membranes and poor skin turgor are signs of dehydration. Loss of subcutaneous tissue that occurs with normal aging makes checking skin turgor of questionable usefulness as a sign of dehydration in elders. In this age group, skin turgor is best assessed over the sternum.

* Pale mucous membranes are indicative of anemia, and thin sparse hair can be a sign of malnutrition. There is some thinning of hair with normal aging, but you would not expect the hair to be sparse.

* Some loss in the size and tone of muscles is expected with aging; however, this would be more pronounced in someone who is malnourished. Skeletal muscle is metabolized for energy if food intake chronically is inadequate.

* Bilateral edema in the extremities indicates that her malnutrition may be significant. Fluids migrate into the tissues because of inadequate serum proteins.

* Kyphosis is often a sign of osteoporosis and vertebral compression fractures indicative of inadequate amounts of calcium over a number of years.

Laboratory findings

* RBC and hemoglobin are low. Anemia is present and the cause needs to be determined. The numbers actually look better than they are because of dehydration.

* Increased hematocrit, sodium, and BUN indicate dehydration.

* Decreased albumin indicates moderate malnutrition. Albumin is sensitive to changes in nutritional status but has a long halflife (17-21 days) and therefore is not a useful measure of current nutritional status. Albumin can also be affected by hydration; T.E's nutritional status is likely poorer than her albumin indicates.

Table 1.

Laboratory Values Related to Nutritional Status

What additional laboratory tests would give better information about her nutritional status? Other fairly common laboratory tests for objective information about nutritional status are pre-albumin and transferrin (see Table 1). Supplementary information can be obtained from iron, iron binding capacity, cholesterol, and total lymph count. Because of the long half-life, albumin is not useful in assessing acute malnutrition or in monitoring the early effectiveness of protein supplementation. Transferrin (half-life 8 to 10 days) and pre-albumin (half-life 2 days) more accurately reflect the current nutritional status and therefore are better tests in those situations. A rise in pre-albumin of 1 mg/day indicates a good response to nutritional intervention.

Problems with Eating and Nutrition Post-Test

1. Which of the following are risk factors for poor nutrition in older people?

a. Oral and dental problems

b. Social isolation

c. Depression

d. Multiple medications

e. All of the above

2. Which of the following statements is generally accurate about the fluid intake in older people?

a. There is no reason for concern; drink as much as they feel like taking,

b. Because of poor kidney function, they need to drink 500 ce a day less than younger adults,

c. They should make sure to drink about 2,000 ce a day, even if not thirsty,

d. Drinking adequate fluid is only a concern if they are constipated.

3. What are some of the reasons for a poor appetite in a hospitalized patient?

a. Illness

b. Being kept NPO

c. Anxiety

d. Not being able to get food that appeals

e. All of the above

4. What are possible community resources that may be helpful to older people who need help getting and preparing food?

a. Area Agency of Aging

b. Informal support from friends and neighbors

c. Meals on Wheels and similar programs

d. Home health aides

e. All of the above

5. Involuntary weight loss of 10 pounds in 6 months should be a trigger for what?

a. A celebration; almost everyone is a little overweight

b. New dentures

c. Evaluation by the individual's primary care provider

d. Speech and swallowing evaluation

Post-Test Answers

1. e

2. c

3. e

4. e

5. c

References

Fischbach, RT. (2004). A manual of laboratory and diagnostic tests (7th ed.). Philadelphia, PA: Williams and Wilkins.

Johnson, L. (1997). Nutrition. In R. Ham & P. Sloane (Eds.), Primary care geriatrics: A case based approach (3rd ed.) (pp. 108) St. Louis: Mosby.

Lee, V., Fletcher, K., Westley, C., & Fankhauser, K.A. (2004). Competent to care: Strategies to assist staff in caring for elders. MEDSURG Nursing, 13(5), 281-289.

Resources

Nutrition

Amelia, E. (1998). Assessment and management of eating and feeding difficulties for older people. Geriatric Nursing, 19(5), 269- 274.

Gammon, S.A., & Hackshaw, H.S. (2000). Are we starving our patients? American Journal of Nursing, 100(5), 43-45.

General Aging

Beers, M.H., & Berkow, R. (2000). Merck manual of geriatrics (3rd ed.). Whitehouse Station, NJ: Merck Research Laboratories.

Ebersole, P., & Hess, P. (Eds.) (1998). Toward healthy aging: Human needs and nursing response (5th ed.). St. Louis: Mosby.

Ham, R.J., Sloane, P.D., & Warshaw, G.A. (Eds.). (1997). Primary care geriatrics: A case-based approach (4th ed.). St. Louis. Mosby.

Lueckenotte, A.G. (Ed.) (2000). Gerontologie nursing (2nd ed.). St. Louis: Mosby.

Virginia K. Lee, MSN, APRN-BC, ANP, is an Advanced Practice Nurse 1, University of Virginia Health System, Charlottesville, VA.

Note: Self-Study Module written by Virginia K. Lee is based on module developed by Alesia Amburn, Carol Clerico, Laura Knotts, Betty King and Virginia Lee in 1996. Copyright 2002 by the Rectors and Visitors of the University of Virginia. Reprinted with permission.

Copyright Anthony J. Jannetti, Inc. Dec 2004

Source: Medsurg Nursing

More News in this Category