Elaine J. Amella

Factors Associated With Weight Loss, Low BMI, and Malnutrition Among Nursing Home Patients: A Systematic Review of the Literature

BACKGROUND Weight loss and poor nutrition are important quality measures in long term care. Long term care professionals need to identify factors associated with weight loss and poor nutrition to target high-risk patients. METHODS The authors systematically searched Medline and CINAHL databases and included English language studies with more than 100 subjects analyzed, published after January 1, 1990, with data on factors associated with at least one of the following: weight loss, low body mass index (BMI), low Mini-Nutritional Assessment (MNA) score, or other standard measure of malnutrition. Data from all studies were systematically extracted onto a matrix table. The Critical Appraisal Skills Programme (CASP) questions were used to compare the quality of evidence extracted. Data from each article were then sorted and arranged into tables of factors associated with weight loss, low BMI, and malnutrition. RESULTS Sixteen studies met the inclusion criteria for the review. The factors most consistently associated with weight loss were depression, poor oral intake, swallowing issues, and eating/chewing dependency. Staffing factors were associated with weight loss in most studies. The factors most consistently associated with low BMI included immobility, poor oral intake, chewing problems, dysphagia, female gender, and older age. The factors most consistently associated with poor nutrition included impaired function, dementia, swallowing/chewing difficulties, poor oral intake, and older age. CONCLUSION Potentially modifiable factors consistently associated with increased likelihood of weight loss, low BMI, or poor nutrition included depression, impaired function, and poor oral intake. Nursing home medical directors may wish to target quality improvement efforts toward patients with these conditions who are at highest risk for weight loss and poor nutrition.

An evolutionary analysis of mealtime difficulties in older adults with dementia

AIMS AND OBJECTIVES To use the evolutionary method of concept analysis to identify attributes, antecedents and consequences of mealtime difficulties providing direction for assessment and management in older adults with dementia. BACKGROUND Mealtimes encompass more than the physical act of feeding a person with dementia. Social and contextual considerations are vital considerations to improving nutritional intake. While feeding difficulties in dementia have been analysed in the literature, this paper proposes a broader scope of mealtime considerations to alleviate nutritional deficiencies often associated with dementia. DESIGN Evolutionary method of concept analysis. METHODS In 2008, literature searches using keywords (meal, history, sociology, mealtime, culture, habit, dementia, dementia) were done in CINAHL, Academic Search Premiere, MasterFILE, Americal Life and History, Communication and Mass Media Complete, EJS, Health Source Plus-Academic, PsychARTICLES and PsychINFO, ScienceDirect, Sociological Abstracts and Google. Year limits were from 1988-2008. A total of 659 abstracts were reviewed, Google, books and textbooks with relevant content. RESULTS Fourty-eight sources were used in the final analysis of mealtime difficulties in older adults with dementia. A model of mealtime difficulties delineates attributes, antecedents and consequences. CONCLUSIONS Mealtime difficulties in dementia emerged as a concept with supporting evidence-based practice guidelines in 2003. Most research has been conducted in institutional settings, but community research is growing as the shifting demographics of ageing demand attention for this setting. Interventions vary in effectiveness for alleviating sequelae of mealtime difficulties in older adults with dementia. RELEVANCE TO CLINICAL PRACTICE The conceptual model of mealtime difficulties provides a broader scope of mealtime difficulties in dementia that considers environmental, social, cultural and contextual implications with nutritional intake. The model can be used to guide future research to alleviate mealtime difficulties in older adults with dementia.

Prevalence and Measures of Nutritional Compromise Among Nursing Home Patients: Weight Loss, Low Body Mass Index, Malnutrition, and Feeding Dependency, A Systematic Review of the Literature

Weight loss and poor nutrition have been important considerations in measuring quality of nursing home care since 1987. Our purpose was to examine, synthesize, and provide a systematic review of the current literature on the prevalence and definitions of nutritional problems in nursing home residents. In the fall of 2011, we performed MEDLINE searches of English-language articles published after January 1, 1990. Articles were systematically selected for inclusion if they presented prevalence data for general nursing home populations on at least one of the following: weight loss, low body mass index, Mini-Nutritional Assessment or other measure of malnutrition, poor oral intake, or dependency for feeding. Data on each study, including study author, year, setting, population, type of study (study design), measures, and results, were systematically extracted onto standard matrix tables by consensus by a team of two fellowship-trained medical school faculty geriatrician clinician-researchers with significant experience in long term care. The MEDLINE search yielded 672 studies plus 229 studies identified through related citations and reference lists. Of the 77 studies included, 11 articles provided prevalence data from the baseline data of an intervention study, and 66 articles provided prevalence data in the context of an observational study of nutrition. There is a wide range of prevalence of low body mass index, poor appetite, malnutrition, and eating disability reported among nursing home residents. Studies demonstrate a lack of standardized definitions and great variability among countries. Of all the measures, the Minimum Data Set (MDS) weight loss definition of ≥5% in 1 month or ≥10% in 6 months had the narrowest range of prevalence rate: 6% to 15%. Weight loss, as measured by the MDS, may be the most easily replicated indicator of nutritional problems in nursing home residents for medical directors to follow for quality-improvement purposes. Additional studies are needed, reporting the prevalence of the MDS weight loss definition among international nursing home residents.

The Influence of Nursing Home Culture on the Use of Feeding Tubes

BACKGROUND Nationwide, many nursing home (NH) residents with advanced cognitive impairment are tube fed, despite no demonstrable benefits of this intervention in this population. Studies suggest that organizational features of NHs are associated with this practice, but underlying reasons for these associations are poorly understood. METHODS We conducted a focused ethnographic study of 2 NHs in South Carolina, 1 with a high tube-feeding rate (41.8%) in patients with advanced dementia, and 1 with a low rate (10.7%). Data were collected about physical environment, mealtime and decision-making processes, and explicit and implicit values using 80 hours of direct observation, semistructured interviews with 30 key facility personnel, and abstraction of publicly available material describing the facilities. Data were analyzed using qualitative methods. RESULTS Striking variations in organizational culture were identified. The low-use NH had a homelike environment centered on food as an important component of daily life, mealtimes staffed with knowledgeable nursing assistants who valued hand feeding, and advance care planning that included family and palliative care options. In contrast, the high-use NH had an institutionlike environment, poorly staffed mealtimes, and staff attitudes favoring feeding tubes to avoid aspiration and to meet perceived regulatory compliance. CONCLUSIONS The NH culture influences the approach to feeding in advanced cognitive impairment, whether by hand or placement of a feeding tube. Key features of NHs with a low rate of tube-feeding use include a physical environment that promotes the enjoyment of food, administrative support, and empowerment of staff to value hand feeding and shared decision-making processes involving family members.

Behavioral Activation and Therapeutic Exposure for Bereavement in Older Adults

The development and clinical trial of a 5-session behavioral intervention for complicated bereavement (CB) is presented. We conceptualized CB in terms of Major Depression (MDD) and Post-traumatic Stress Disorder (PTSD) and consequently applied treatment components of Behavioral Activation and Therapeutic Exposure (BA-TE). In order to assure standardization of treatment, control costs, and engage patients, a multi-media, multi-context format was adopted to address avoidance and withdrawal behaviors conceptualized as central pathogenic responses in CB. Participants (N = 26) were assessed before and after BA-TE treatment via structured clinical interview and standardized questionnaires in terms of PTSD, MDD, CB, and health concerns. The number of days since the death of the loved one was widely variable and served as a covariate for all outcome analyses. ANCOVAS revealed statistically significant improvement, irrespective of how many days since death had elapsed prior to initiation of intervention, on structured interviews and self-report measures for most outcome variables.

Eating Behavior in Persons With Moderate to Late-stage Dementia: Assessment and Interventions:

Persons with various forms of dementia suffer from a progressive disease in which memory and the ability to function independently are lost. During moderate to late-stage dementia, individuals experience increased difficulty with eating and require more feeding assistance. Clinicians working with this population must acknowledge the multifactorial aspects of eating behavioral issues, use a team approach, and make careful assessments using appropriate instruments. Interventions should include attention to cognitive impairment, nutritional intake, training of caregivers, modification of the environment, and the quality of the interaction. Planning for care should include promoting the highest quality of life for these individuals and their caregivers. J Am Psychiatr Nurses Assoc, 2008; 13(6), 360-367.

Partners for NP education: the 1999 AANP preceptor and faculty survey.

Purpose To increase understanding of national trends in nurse practitioner (NP) clinical education, the Education Committee of the American Academy of Nurse Practitioners (AANP) con‐ducted a survey at the 1999 National AANP Conference in Atlanta. Data Sources A convenience sample of preceptors (n=87) and faculty (n=42) out of the total attendance of 1,744 responded to a written questionnaire. Conclusions Preceptor respondents provided data concern‐ing the number of NP students supervised, influence of student supervision on productiv‐ity, and availability of incentives for precept‐ing. Faculty reported placement and supervi‐sion issues, the extent of precepting in their clinical practice site, and recognition and sup‐port for this role. Faculty and preceptors dis‐agreed about the types and number of incen‐tives offered for accepting students as well as the congruence of clinical teaching activities and national teaching guidelines. Precepting did not appear to strongly influence preceptor productivity. External funding did not influ‐ence opportunities for clinical education. Implications for Practice In 1998, the graduates of NP programs rose by 15.8% and over half of all nursing students enrolled in graduate nursing programs were seeking a NP education. This increase in stu‐dents may compromise the ability of schools of nursing to insure quality clinical education of NP students by increasing faculty workload and placing greater demands on expert precep‐tors in the community. Clinical education is also changing in light of changes in the health care system.

State of the science: Alleviating mealtime difficulties in nursing home residents with dementia

Three million people will reside in nursing homes (NH) in the United States, and over 50% will experience some level of dementia by 2030. People with dementia become increasingly dependent on others to manage mealtime difficulties and oral intake as the disease progresses. The purpose of this review is to explore the state of the science related to assisted hand-feeding of people with dementia in the NH, identify gaps, and inform future policy. The review was conducted in 2010 and identified sources from journal articles, websites, and other related publications. Results are presented around key themes of characteristics, measurements, related factors, and interventions for alleviating mealtime difficulties in people with dementia. Though in the early stages, international and interdisciplinary research interest exists to understand mealtime difficulties and effective intervention strategies. Health care providers must be able to identify problems and intervene appropriately to alleviate mealtime difficulties.

End-of-life communication and hospital nurses: an educational pilot.

Heart failure is a high prevalence, high burden disease with an unpredictable trajectory. Given that approximately 50% of persons with the diagnosis die within 5 years, the implications for communication about advance planning and end of life, although simultaneously providing hope and treatment, are extremely challenging. This article reports on a feasibility trial of a modest continuing education seminar to increase awareness and communication skills of inpatient nurses. Curriculum design details, including objectives and methods, are described. Needs assessment and evaluation data are reported. At the 2-month posttest, a summary communications skill score showed significant improvement. Data also illustrated that the challenge of facing issues about dying are complicated by a work force of relatively young staff and low exposure to few actual deaths during relatively short lengths of stay.

Dementia-Related Mealtime Difficulties: Assessment and Management in the Long-Term Care Setting

By the year 2050, the number of persons with dementia aged 65 and older in the United States is expected to increase from 5.4 to 16 million persons [1]. While most persons with dementia (PWD) prefer to be cared for in their home environment, as the disease causes progressive functional and behavioral decline many will require institutional care. For these PWD, this means placement in assisted-living facilities or skilled nursing homes (NH). The number of PWD in the NH setting is expected to double to three million by the year 2050 [1]. While NHs attempt to address the multiple needs of their residents, the very basic need for adequate nutrition to promote health may be compromised by frailty, chronic illness, and cognitive decline.