Geriatric Nutrition

1. Geriatric Nutrition By Robin Cote, MS, RD/LD, CSG

2. Objectives • Understand the role of the RD in long-term care • List risk factors associated with weight loss in elderly • Perform comprehensive nutritional assessment of geriatric population • Describe energy, protein and fluid needs for elderly • Assess nutritional needs for patients with pressure ulcers • Create appropriate PES statements for nutrition care process of geriatric population • Explain the roles of the long-term care regulatory agencies

3. Aging • Definition: • Gradual change in an organism that leads to increased risk of weakness, disease, and death. It takes place in a cell, an organ, or the total organism over the entire adult life span of any living thing. There is a decline in biological functions and in ability to adapt to metabolic stress. Changes in organs include the replacement of functional cardiovascular cells with fibrous tissue. Overall effects of aging include reduced immunity, loss of muscle strength, decline in memory and other aspects of cognition, and loss of color in the hair and elasticity in the skin. In women, the process accelerates after menopause. Webster’s Dictionary

4. Aging Terms • “Young Old” • 65-74 years old • 1% in LTC • “Middle Old” • 75-84 years old • 6% in LTC • “Oldest Old” • >85 years old • 22% in LTC

7. Baby Boomer Statistics • Between 1946-1964 • 75.8million Americans were born • Represents about 28% of the U.S population • Another boomer turns 50 every 7 seconds • Between 2010 and 2030 – elderly population explosion as Baby Boomers turn 65

8. Baby Boom “bulge”

9. Florida • The state of Florida has the largest percentage of seniors in the U.S. • Florida contains 683 certified Medicare and Medicaid nursing homes • Total of 82,720 available beds for skilled nursing residents • ~87% of those beds are fullon average • The overall average Medicare 5 Star Quality rating for Florida skilled nursing homes is 3.3 which ranks 21 nationally • The Florida Legislature developed a comprehensive legislative statute known as Chapter 400, which protects residents of nursing homes and related health care facilities • Fines and penalties for not abiding by the laws of this statute

10. Common characteristics and issues associated with old age… • Depression • Living alone • Loneliness • Limited Income • Falls • Dementia • Decreased mobility and risk for falls • Decrease in ability to perform ADL’s • Risk for skin breakdown • Malnutrition • Dehydration • Poor dentition • Swallowing difficulty • Hearing loss • Vision loss • Multiple co-morbidities • Polypharmacy • Osteoporosis • UTI’s • Taste alteration • Mortality

11. Long-term Care • 7 out of 10 residents are women • 79 years old = average age upon admittance to a nursing home • 40%of individuals who reach age 65 who will enter a nursing home during their lifetimes • 892 days (2.44 years): Average length of stay for current nursing-home residents, 1999 • 272 days (8.94 months): Average length of stay for discharged nursing-home residents, 1999

12. Long-term Care • 40% of the older population with long-term care needs who are poor or near-poor • 49% nursing home costs covered by Medicaid, 2002 • 25% of nursing home costs paid out of pocket, 2002 • 7.5% of nursing home costs covered by private insurance, 2002 • $86,140: Annual cost of nursing home care in Tampa, FL

13. Long-term Care • 68%: The probability that an individual over age 65 will become cognitively impaired or unable to complete at least two "activities of daily living"--including dressing, bathing, or eating--over his or her lifetime • 42%of individuals in nursing homes who are experiencing some form of dementia • 33% of individuals in nursing homes who are suffering from some form of depression • 38% of nursing home patients who will eventually be discharged to go home or to another setting • 10% of people who enter a nursing home who will stay there five or more years • 65% of people who entered a nursing home who died within one year of admission

14. Hospital Readmissions • 40% of Medicare patients who are discharged from hospitals are admitted to a skilled nursing or rehab facility to complete their recovery • < 30 days, nearly 1 in 5 of these patients will be readmitted to hospital • “Revolving door” of rehospitalization from nursing facilities is a growing problem in the U.S.

15. Medicare Costs • Medicare Costs for rehospitalized patients: • 2006: $4.3 billion • 2013: $17 billion

16. Making Hospitals Accountable • The Patient Protection and Affordable Care Act of 2010 specifically addresses the problem, and starting in 2013, allows Medicare to level financial penalties for hospitals based on readmission rates • Prospect of penalties and payment model changes based on rehospitalization rates has forced many hospitals and nursing homes into taking action to lower their readmission rates

17. Making Hospitals Accountable • Hospitals with higher-than-average rates of readmission will face financial penalties • By 2013, the Patient Protection and Affordable Care Act will allow CMS to withhold a percentage of inpatient Medicare payments based on a hospital’s aggregate Medicare payments for all discharges • Penalties start at up to 1% withheld from Medicare payments in 2013 • By 2015 penalties up to 3%

18. Questions for LTC to consider: • Could this transfer have been avoided? • Were there “early warnings” of a decline in the patient’s condition? • Could precautions have been taken? • Could the nursing home have provided the acute care the patient needed? • How can we avoid rehospitalization next time?

19. Why is it important to decrease hospital readmission rates? • Financial impact for hospitals due to Medicaid penalties • Hospital will acquire reputation for poor quality of care • The stress of a transfer on a resident can lead to medical and emotional setbacks that can delay and extend recovery • Resident well-known by staff at LTC facility

20. Interdisciplinary Team • “A team effort is probably the single most important factor in reducing hospital readmission rates from nursing homes”(Brian Karstetter, regional VP of operations for ReveraHealth Systems) • Physician • Nurses • Pharmacist • Psychiatrist and psychologist • Therapy (ST, OT, PT) • Social Worker • Registered Dietitian and CDM • Recreation Therapist • Volunteers

21. AHCA, CMS and DCF • Centers for Medicare and Medicaid Services (CMS) • US federal agency which administers Medicare, Medicaid, and the State Children's Health Insurance Program • Agency for Healthcare Administration (AHCA) • “responsible for the administration of the Medicaid program, for the licensure and regulation of health facilities and for providing information to Floridians about the quality of the health care they receive in Florida” • Department of Children and Families (DCF) • All abuse must be reported to DCF • Abuse hotline 1-800-96-ABUSE

22. Ombudsman Program • Definition: • Ombudsmen – An ombudsman is a volunteer advocate for people who live in nursing homes, assisted living facilities and adult family care homes. All services are confidential and free of charge. (http://ombudsman.myflorida.com) • Duties of Ombudsmen: • “Provides a voice for those who may not be able to speak up for themselves” • Advocate for resident rights • Investigate and resolve the concerns or complaints of residents and their loved ones • Annual assessment of all facilities

23. MDS 3.0 • Minimum Data Set (MDS): Tool for facilitating care management in nursing homes developed by CMS • Federally mandated process for clinical assessment of all residents in Medicare and Medicaid-certified nursing homes • Provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems • Care Area Assessments (CAAs) are part of this process, and provide the foundation upon which a resident's individual care plan is formulated

24. MDS 3.0 (cont’d) • MDS assessments are required for residents on admission to the nursing facility, quarterly, and when significant change occurs, and on discharge • All assessments are completed within specific guidelines and time frames • In most cases, participants in the assessment process are licensed health care professionals employed by the nursing home • Section K – Oral/Nutrition Status • MDS information is transmitted electronically by nursing homes to the national MDS database at CMS

25. Care Plans • Regulation 483.20 in Florida Statute states: “The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident’s medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment” • Care plans must be completed within 7 days of comprehensive assessment completion • Must be reviewed on quarterly basis with resident and/or family • Attended by entire interdisciplinary team

26. Care Plans (cont’d) • Guidelines for developing care plans: • Individualize care plans • Focus on all assessed problems and potential risks • Provide clear and concise problem statements • Involve the resident and/or family in process • Involve all members of the IDT • Use appropriate and measurable goals and objectives

27. Types of facilities • SNF – Skilled Nursing Facility • Provides long-term care and rehab services • Significant ADL deficiency • Nursing care is 24/7 • ALF – Assisted Living Facility • Provide personal care services in the least restrictive and most home-like environment • Nursing services not available 24 hrs • Needs assistance with 1 ADL • IL – Independent Living • 55 years and older • Do not provide health care • Senior-friendly surroundings with social activities

28. Types of facilities (cont’d) • ECC – Extended Congregate Care or CCRC – Continuing Care Retirement Community • Includes SNF, ALF and IL • Provides residents the ability of remaining in a familiar setting as they become more impaired or need more care for a short period of time • “Age in place” • Average CCRC in U.S. contains ~330 units • 230 independent or congregate living units • 40 assisted living beds, and • 60 skilled nursing home beds

29. Types of facilities (cont’d) • Respite Care – temporary care provided by facility • Allows a break for the caregiver • Part of the Medicare Hospice Benefit • Hospice Care • Provide inpatient and outpatient end of life care • Dementia Unit or Special Care Unit (SCU) • ALF or SNF • To better meet needs of Alzheimer’s dementia patients • Provides protection for those without dementia

30. Benefits of Special Care Units • Continuous pathways to allow patients to wander • Locked unit provides decreased risk of elopement • Less need for physical or chemical restraints • Safer environment for these patients and non-dementia patients • Relaxed atmosphere to avoid over stimulation and reduce agitation and confusion • Less background music, TVs, announcements • No telephones • Open floor plan for easy visual access • Color-coded halls • Personal, identifiable pictures next to door • More individualized care due to lower staff-to-resident ratio • Specialized training and knowledge of staff • Private dining room and activities room

31. Caregivers • Definition: unpaid assistance for the physical and emotional needs of another person, ranging from partial assistance to 24-hour care • Other considerations: • Often do not take care of themselves • Often must juggle taking care of their own family and children, working outside the home and caring for an aging parent • Important to seek help from others • Level of care typically progresses • Financial burden

32. Caregivers • Feelings experienced by caregivers • Sadness and grief • Stressed • Burned out • Fatigue • “Tied down” or isolated • Anger and frustration • Fear and worry • Depression • Guilt

33. Polypharmacy • Defined as use of 5 or more medications • Common in elderly • Estimated to cause the death of 100,000 older adults each year • Many medications are taken unnecessarily • Drug-drug interactions • Drug-nutrient interactions • Increased side effects • High cost • Associated with increase risk of falls in the elderly • Associated with decreased quality of life • Risk of poor compliance to medications due to pill burden

34. Polypharmacy (cont’d)Symptoms: • Fatigue or decreased alertness • Constipation, diarrhea or incontinence • Loss of appetite • Confusion, either continuous or episodic • Falls • Depression or general lack of interest • Weakness • Tremors • Hallucinations • Anxiety or excitability • Dizziness • Decreased sexual behavior • Skin rashes

35. BEERS Criteria • Developed in 1991 by Mark Beers, geriatrician • Updated in 1997, 2003, 2011 • 2012 American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults • List of medications generally inappropriate for people 65 and older because the risk outweighs the benefit • 3 categories: • 1. medications that are potentially inappropriate for older people because they either pose high risks of adverse effects or appear to have limited effectiveness in older patients • 2. medications that are potentially inappropriate for older people who have certain diseases or disorders because these drugs may exacerbate the specified health problems • 3. medications to be used with caution in older adults

36. Factors that Contribute to Noncompliance with Drug Therapy (Geriatric Nutrition by Chernoff) • Borrowing/sharing medication • Cognitive deficits/memory loss • Drug cost • Hoarding medication for future use • Improper storage/transferring to another container • Lack of understanding • Number of medications • Physical limitations (can’t read label, can’t open container) • Scheduling difficulties • Transportation issues • Using expired medications

37. Age-related physiologic changes that can effect drug efficacy • Diminished renal function – single most important factor responsible for altered drug levels in elderly • GFR falls approx 1 ml/min each year after 40 years • Decline in efficiency of mechanisms that metabolize drugs • Decreased salivation, gastric acidity, GI motility • Increased transit time • Decreased hepatic function • Decreased cardiac output

38. Medications commonly used in LTC with nutritional concerns • Dilantin • May decrease folate, calcium and B12 levels • Hold TFs 1 hour before and 1 hour after Dilantin dose • Dilantin will bind to protein in EN and not be as therapeutic • Antibiotics • Can cause GI upset (N/V/D) which may impact appetite • Diuretics (Lasix, Bumex, HCTZ) • May need potassium supplement • May result in weight loss or weight fluctuation • Monitor for dehydration

39. Medications commonly used in LTC with nutritional concerns • Laxatives • May cause weight loss or weight fluctuation • Monitor for dehydration • Fiber supplement • Requires large volume of fluid • Helps to bulk stool • Steroids • Can cause increased appetite, weight gain, increased blood sugar levels • Decreases absorption of calcium in gut • May need Ca supplement if steroids are long-term

40. Medications commonly used in LTC with nutritional concerns • Psychotropics • Side effects include anorexia, diarrhea, N/V, increased/decreased appetite, dry mouth • Hypoglycemic agents (OHA’s) • Can cause GI distress • Iron • Absorption increased with Vitamin C • Do not give within 2 hours of Calcium supplement

41. Medications commonly used in LTC with nutritional concerns • MVI or MVI w/ min • Recommend if poor PO intake or pressure ulcer • Absorbed best with food • Vitamin D • Increases calcium absorption • Kidneys synthesize Vitamin D, so may need supplement if renal dysfunction • Vitamin D deficiency common in elderly • Levodopa • Vitamin B6 reduces effectiveness • Protein may interfere with the body's response to levodopa • High protein diets should be avoided • Intake of normal amounts of protein should be spaced equally throughout the day

42. Medications commonly used in LTC with nutritional concerns • Phosphorus Binders • May cause constipation, anorexia, nausea • Do not give at same time as calcium or iron supplement • Take with meals • Large pills • Patients often refuse to take them; poor compliance • Potassium • Can be bitter tasting • Disguise with fruit juice

43. Medications commonly used in LTC with nutritional concerns • Appetite Stimulants • Megace and Megace ES • Hormone also used to treat breast cancer, hot flashes • Can cause increased BG’s and increased risk for DVT’s • Oxandrolone • Anabolic steroid • Marinol • Marijuana derivative • Periactin • Antihistamine w/ side effect of increased appetite • ElderTonic • Vitamins, minerals and alcohol • Remeron • Anti-depressant with side effect of increased appetite

44. Factors affecting Food Choices of Elderly (Geriatric Nutrition by Chernoff) • Poverty • Social isolation/depression • Loss of spouse • Physical disability • Poor dentition • Chronic drug therapy • GI disorders/malabsorption • Disease/pathologic processes • Alcoholism • Inadequate knowledge of nutrition

45. Nutrient Deficiency – Calcium • Elderly prone to calcium deficiency • Increased lactose intolerance with age leads to reduced intake of calcium-rich dairy products • Calcium absorption via active transport can decrease with age • Calcium deficiency may result from Vitamin D deficiency • Corticosteroids can inhibit calcium absorption • Most menus meet 100% RDA for calcium, however if resident not drinking milk, may need calcium supplement • AI = 1,200 mg/day for >51 years old

46. Nutrient Deficiency – Vitamin D • Elderly have increased risk of Vitamin D deficiency • Kidneys become less able to convert Vitamin D to its active form • Synthesizing Vitamin D in older adults becoming less efficient • By age 70, Vitamin D synthesis expected to decrease by 75% • Not consuming enough Vitamin D in diet over time • Don’t always eat 100% of meals • Only select foods contain Vitamin D, which means fortified foods provide most of the Vitamin D in the diet • Limited exposure to sunlight • AI = 400 IU ages 51-70 years old • AI = 600 IU > 70 years old • Extra 1,000 IU recommended for elderly

47. Nutrient Deficiency – Vitamin B12 • Increased gastric atrophy and decreased gastric pH with age, which may result in decline in serum B12 levels • Malabsorption of B12 in elderly • Elderly have lower intake of B12 in diet • Primary dietary source is animal products • Meats may be avoided due to difficulty chewing or swallowing, high cost, or difficulty in preparation • B12 supplement may be needed to meet needs • RDA = 2.4 mcg/day

48. Nutritional Screening in LTC • Poor intake of food, fluid or supplement • Significant weight change • Abnormal lab values • Presence of pressure ulcers • Receiving nutrition support • Receiving dialysis • Other relevant conditions or diagnoses, such as dysphagia, constipation, edema, dementia, terminal disease, diabetes, total dependence on staff for feeding, etc.

49. Nutrition Assessment • Age • Gender • Height • Weight • BMI • IBW • % Weight Change • UBW • Patient’s Desired Weight • Labs • Meds • Difficulty chewing or swallowing • PMH and PSH • Diet Hx • Food Intolerances • Food Allergies • Food Preparation • Food Availability

50. Significant Weight Loss • 5% in 30 days • 7.5% in 90 days • 10% in 180 days • Must be documented in record and in MDS • Nutrition documentation and interventions • Family, physician and resident (if applicable) must be made aware of weight loss • Monthly weights and weekly weights • Many facilities document if >2% in 1 week