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Guideline Summary
Guideline Title
Altered nutritional status in the long-term care setting.
Bibliographic Source(s)
American Medical Directors Association (AMDA). Altered nutritional status in the long-term care setting. Columbia (MD): American Medical Directors Association (AMDA); 2010. 35 p. [71 references]
Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: American Medical Directors Association (AMDA). Altered nutritional status. Columbia (MD): American Medical Directors Association (AMDA); 2001. 32 p.

Scope

Disease/Condition(s)

Altered nutritional status (ANS)

Guideline Category
Diagnosis
Evaluation
Management
Risk Assessment
Screening
Treatment
Clinical Specialty
Geriatrics
Internal Medicine
Nutrition
Intended Users
Advanced Practice Nurses
Allied Health Personnel
Dietitians
Health Care Providers
Nurses
Pharmacists
Physician Assistants
Physicians
Social Workers
Speech-Language Pathologists
Guideline Objective(s)
  • To improve the quality of care delivered to patients in long-term care settings
  • To help the interdisciplinary team evaluate and manage nursing home residents who are at risk for or who have experienced a significant change in weight
  • To provide a structured approach to the recognition, assessment, treatment, and monitoring of altered nutritional status (ANS) that acknowledges the ethical implications of this condition for patients, their families, and the staff of long-term care facilities
  • To inform institutional policies and procedures and the survey processes of state and federal reviewers
Target Population

Residents of long-term care facilities who are at risk for or who have experienced a significant change in weight

Interventions and Practices Considered

Screening/Diagnosis/Evaluation

  1. Baseline evaluation of patients' nutritional status (weight, height, body mass index, eating preference, laboratory tests [albumin, cholesterol, complete blood count with differential], Minimum Data Set [MDS], Mini-Nutritional Assessment [MNA])
  2. Identification of risk factors for altered nutritional status (ANS)
  3. Routine observation of patient for changes in weight or food intake that may indicate ANS
  4. Tier I and Tier II assessment to identify causes of nutritional problems
  5. Screening as indicated for functional impairments, social and environmental factors, dietary restrictions, food preferences, medical conditions associated with anorexia or dehydration, malabsorption syndrome and conditions that increase nutritional needs, conditions related to fluid retention (if weight gain)
  6. Identification and documentation of unavoidable ANS

Management/Treatment

  1. Nutrition, medical, functional and nursing care planning to address identified risk factors and potential causes of altered nutritional status
  2. Management of eating environment
  3. Rehabilitation for functional disabilities
  4. Tailoring meals and foods to individual preferences
  5. Reconsideration of dietary restrictions
  6. Dietary supplements
  7. Appetite stimulants
  8. Tube feeding
  9. Monitoring risk factors and effectiveness of treatment interventions
Major Outcomes Considered
  • Risk for altered nutritional status
  • Nutritional status
  • Weight and body mass indices (BMI)
  • Appetite

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

Medline, PubMed, and geriatric-specific journals such as the Journal of the American Medical Directors Association (JAMDA), Annals of Long Term Care, and Journal of the American Geriatrics Society (JAGS) were searched from May 2009 through February 2011. Studies were included if they met the following criteria:

  • Studies that are valid, consistent, applicable and clinically relevant
  • Studies where the recommendation is supported by fair evidence (based on studies that are valid, but there are some concerns about the volume, consistency, applicability and clinical relevance of the evidence that may cause some uncertainty but are not likely to be overturned by other evidence).

Searches were specific to the guideline topic under consideration.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Expert Consensus
Rating Scheme for the Strength of the Evidence

Not applicable

Methods Used to Analyze the Evidence
Review
Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

Original guidelines are developed by interdisciplinary workgroups, using a process that combines evidence and consensus-based approaches. Workgroups include practitioners and others involved in patient care in long-term care facilities. Beginning with a general guideline developed by an agency, association, or organization such as the Agency for Healthcare Research and Quality (AHRQ), pertinent articles and information, and a draft outline, each group works to make a concise, usable guideline that is tailored to the long-term care setting. Because scientific research in the long-term care population is limited, many recommendations are based on the expert opinion of practitioners in the field. A bibliography is provided for individuals who desire more detailed information.

Guideline revisions are completed under the direction of the Clinical Practice Guideline Steering Committee. The committee incorporates information published in peer-reviewed journals after the original guidelines appeared as well as comments and recommendations not only from experts in the field addressed by the guideline but also from "hands-on" long-term care practitioners and staff.

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation

All American Medical Director Association (AMDA) clinical practice guidelines undergo external review. The draft guideline is sent to approximately 175+ reviewers. These reviewers include American Medical Director Association physician members and independent physicians, specialists, and organizations that are knowledgeable of the guideline topic and the long-term care setting.

AMDA's guidelines are supported by the following associations/organizations, who are members of its Clinical Practice Guideline Steering Committee. These associations/organizations all have representatives who participate in the external review phase and officially sign off on the guideline before publication: American Association of Homes and Services for the Aging (Now LeadingAge); American College of Health Care Administrators; American Geriatrics Society; American Health Care Association; American Society of Consultant Pharmacists; Gerontological Advanced Practice Nurses Association; Direct Care Alliance; National Association of Directors of Nursing Administration in Long-Term Care; National Association of Health Care Assistants.

Recommendations

Major Recommendations

Note from the American Medical Directors Association (AMDA) and the National Guideline Clearinghouse (NGC): The original full-text guideline provides an algorithm on "Altered Nutritional Status" to be used in conjunction with the written text. Refer to the "Guideline Availability" field for information on obtaining the algorithm, as well as the full text of the guideline, which provides additional details.

Recognition

Step 1

Perform a baseline evaluation of the patient's nutritional status.

Because nutritional status is often compromised by events (such as hospitalization) that precede admission to a long-term care (LTC) facility, it is important to evaluate nutritional status as soon as possible after each patient's admission. Record the following information in the patient's chart within 14 days of admission:

  • Admission weight
  • Height and body mass index (BMI)
  • Eating preferences
  • Baseline testing
  • Minimum Data Set (MDS)
  • Mini-Nutritional Assessment (MNA)

Step 2

Identify risk factors for altered nutritional status (ANS).

Nearly every patient admitted to an LTC facility is likely to exhibit one or more of the risk factors described below. However, individual patients' overall risk depends on their specific circumstances. Therefore, seek information about the presence of each of the following risk factors for all newly admitted patients.

  • History of recent weight loss or change in appetite
  • Functional disability (including signs of possible dysphagia [see Table 3 in the original guideline document])
  • Pressure ulcer(s)
  • Terminal illness
  • Depression
  • Medication use
  • Therapeutic diets
  • Nausea, vomiting, or diarrhea
  • Fluid retention and edema
  • Underlying infection

Step 3

Observe the patient routinely for changes in weight or food intake that may indicate ANS.

At any time during a patient's stay in an LTC facility, observation of any one of the following conditions should trigger a prompt initiation of an assessment of the patient's nutritional and fluid status (see Step 5):

  • Weight change of 5% in 1 month or 10% in 6 months
  • Decline in food or fluid intake over several days (not to exceed 7 days). An abrupt change, such as refusal of food or fluids for two or more successive meals, usually indicates a medication side effect or the presence of an acute illness rather than a nutritional problem
  • BMI approaching the underweight range. Determine the usual BMI for the patient and define a desirable BMI. People who are constitutionally thin may need closer monitoring, even though they are within their normal weight range, because their physiologic reserves are low
  • Persistent, unexpected, and unintended weight loss for 3 consecutive months
  • Pressure ulcers
  • Abnormal laboratory values
  • Uncontrolled disease process (e.g., chronic obstructive pulmonary disease, diabetes, renal disease)

Assessment

The following steps are intended to guide the diagnostic assessment of patients who meet one or more of the ANS criteria listed in Step 3. The diagnostic process has been divided into two tiers.

  • Tier I is intended to identify causes of a nutritional problem that are common, easily identified, and reversible in some cases.
  • Tier II is intended to identify uncommon conditions or diagnoses for which cure is less likely. Such conditions are important because they may affect prognosis, alter the goals of care, and redirect the care plan. A Tier II assessment is not appropriate in all cases; some patients and families may choose to forego this assessment for personal reasons.

Tier I Assessment

Step 4

Confirm the existence of a nutritional problem that requires additional assessment.

  • Validate weight measurements before initiating an interdisciplinary assessment of ANS.
  • Evaluate whether the patient's weight change (loss or gain) is truly unintended or unexpected.
  • Evaluate the patient's willingness to undergo a diagnostic assessment.

If this review confirms the presence of a problem that requires additional assessment, mobilize the interdisciplinary team to help identify the underlying causes of the problem and develop an individualized treatment plan. If the Step 3 assessment criteria are met but the patient or family decides not to intervene, this decision and the rationale for it should be clearly documented in the patient's record. (See Step 13.) For the patient who triggers an assessment because of weight gain, skip to Step 10.

Step 5

For a patient who has lost weight: Establish that the patient is eating the food he or she receives.

Monitor the patient's food intake for at least 1 day (some dietitians prefer a 3-day evaluation). A simple estimate of the fraction of each portion or food from each food group consumed at each meal is usually sufficient; a calorie count may not be necessary. Refer to the original guideline document for a discussion of anorexia, weight loss that occurs despite normal intake, and hyperphagia.

Step 6

For patients whose food intake is inadequate: Screen for functional impairments.

  • Observe the patient while he or she is eating.
  • Evaluate the patient for oral pain caused by tooth decay, poorly fitting dentures, or gum pathology.
  • Observe the patient's swallowing ability.
  • Evaluate whether adequate feeding assistance is available and whether the time set aside for meals is sufficient for patients who eat slowly.

Step 7

For patients whose food intake is inadequate: Screen for social and environmental factors, dietary restrictions, and food preferences.

Step 8

For patients whose food intake is inadequate: Screen for medical conditions associated with anorexia or dehydration.

  • Consider fluid and electrolyte imbalance.
  • Look for and evaluate any changes in the patient's mood or behavior.
  • Comprehensively review all medications (refer to Table 5 in the original guideline document for medications that may be associated with ANS).
  • Consider the presence of infections.
  • Consider gastrointestinal pathology and motility disorders.
  • Order a chest X-ray and a panel of laboratory tests (see Table 6 in the original guideline) if indicated, to screen for occult physical illness.

Step 9

For patients who lose weight despite normal intake: Screen for a malabsorption syndrome and for conditions that increase nutritional needs.

Patients who lose weight despite normal intake generally fall into one of three categories: those receiving inadequate servings of food, those whose metabolic need is greater than their usual level of food consumption, and those with a malabsorption disorder.

Step 10

Screen patients who gain weight for conditions related to fluid retention.

Tier II Assessment

Step 11

For patients who have lost weight: Evaluate whether a continued search for the cause of weight loss is appropriate.

The Tier II Assessment for patients who have lost weight is more likely than the Tier I Assessment to conclude with the discovery of an irreversible or terminal diagnosis.

When no terminal condition can be clearly identified, the patient's care goals and willingness to undergo more intensive medical evaluation must be considered in determining whether a continued search for the cause of weight loss is appropriate. If it is decided to continue, the interdisciplinary team should take the following measures:

  • Repeat the patient's history and physical examination in light of the recent weight change.
  • Order additional laboratory and radiologic studies on the basis of any new findings in the "second-look" history and physical examination.

Refer to Table 7 in the original guideline document for a partial list of unusual causes of ANS.

Step 12

For patients who have gained weight: Evaluate whether a continued search for the cause of weight gain is appropriate.

A Tier II Assessment is indicated for a patient who has gained weight in the following cases:

  • To determine whether the cause of weight gain is fluid retention.
  • To determine whether the weight gain has negatively affected function, quality of life, or the management of comorbid conditions (e.g., diabetes). Such patients should be evaluated for metabolic conditions associated with weight gain (e.g., hypothyroidism), and their medications should be reviewed for possible drugs that can cause weight gain (e.g., antipsychotics). Psychological evaluation may be indicated to evaluate for a possible psychological cause for the weight gain (e.g., depression).

Step 13

Identify and document unavoidable ANS.

Assessment and treatment of a nutritional diagnosis must be consistent with the patient's individual care goals and must offer a benefit to the patient.

Step 14

Summarize the results of the assessment of the patient's ANS.

This summary should provide the following information:

  • Documentation of ANS, indicating the extent of the weight loss or gain
  • A description of all identified or probable conditions contributing to ANS
  • A projection of the patient's prognosis and likely clinical course
  • Updates to the patient's care plan to indicate all palliative care interventions, with concurrent documentation in a progress note to evaluate their effectiveness

Treatment

Treatment is defined in this guideline as any intervention that offers a reasonable expectation of benefit for the patient. Treatment may include making changes in the dining environment, offering rehabilitation for functional disabilities, offering choices in food and fluids, offering choices in dining alternatives, and controlling or mitigating the effects of medical conditions associated with ANS.

Treatment may be considered successful when the patient's weight has stabilized, even if it stabilizes at a level below baseline. The patient does not have to regain the weight lost. Older adults tend not to return to their previous weight after an illness or temporary nutrient and fluid deficiency.

Step 15

Address each identified risk factor and potential cause of ANS identified in the Recognition and Assessment phases (see Steps 1-13).

The nutrition, medical, functional, and nursing care plans should address identified risk factors and the associated causes identified in the diagnostic assessment. For each identified risk factor, establish a planned intervention.

  • Treat depression.
  • Reassess all medications for continued indications, potential side effects, and interactions that may affect nutritional status.
  • Evaluate the patient's activity level and ability to exercise (exercise can stimulate appetite).
  • For a verified swallowing problem, consider the underlying causes and patient prognosis and determine whether the patient is a candidate for rehabilitation.

Step 16

Address issues that may affect the eating environment in the LTC facility.

  • Ensure that the environment where meals are served is pleasant and conducive to eating.
  • Make every effort to ensure that all foods offered are attractive and palatable.
  • Consider having more than one meal sitting.
  • Adopt a flexible staffing pattern that enables nursing staff to move to floors or units where more patients need assistance during meals.
  • Use non-nursing staff and volunteers at mealtimes to help set up trays and enhance socialization. Only certified nursing assistants and other properly trained staff, however, should feed patients with dysphagia and other swallowing disorders.
  • Consider having a happy hour before dinner, when patients may congregate and have an alcoholic beverage or sweets before their meals.
  • Try using the smell of freshly cooked food to stimulate appetite.

Step 17

Tailor meals and foods to individual preferences.

Each patient has a lifetime of eating habits and food preferences that are based on ethnic, regional, and personal tastes. By adopting a flexible approach to food service and presentation, facilities can meet the challenge of satisfying individual preferences in an institutional setting.

Step 18

Reconsider any dietary restrictions.

Routine dietary restrictions are usually unnecessary and can be counterproductive in the LTC setting.

Late-stage renal insufficiency is an exception to this general rule; protein restriction in patients with late-stage renal insufficiency may delay the onset of dialysis.

Step 19

Consider ways to supplement the patient's diet.

  • Increase the nutrient density of foods.
  • Offer snacks as part of a defined between-meal snack program, for example, during or after a group activity.
  • Consider giving a dietary supplement as a daily multivitamin and mineral supplement (preferably in a liquid form) to patients.
  • Distribute liquid nutritional supplements during the medication pass.

Step 20

Consider the use of appetite stimulants on an individual basis.

Increased exercise may be an appropriate, nonpharmacologic approach to appetite stimulation in some patients. The use of medications to stimulate appetite in LTC patients is controversial. In general, such medications have not been adequately studied and are not part of the routine evaluation and treatment of weight loss in the LTC setting. However, their use may be considered on an individual basis.

Step 21

Evaluate the risks and benefits of artificially administered nutrition and hydration by tube feeding.

Tube feeding may be clinically appropriate in certain circumstances (see Table 8 in the original guideline document), but it should not be an automatic next step when other feeding strategies have failed. Table 9 in the original guideline provides the federal surveyors' guidelines on the use of feeding tubes.

In general, tube feeding may be appropriate when:

  • There is a clear clinical indication for its use,
  • It provides a benefit that is not outweighed by risks, and
  • It is consistent with the known values and preferences of the patient and family.

Step 22

Summarize the results of treatment interventions on the patient's ANS.

Weight stabilization is the primary endpoint. Individual interventions may need to be tried for up to 2 to 3 months before their effectiveness can be determined.

During therapeutic trials, progress notes should briefly describe the following:

  • The treatment plan and the patient's compliance with it
  • Complications or side effects of interventions
  • Trends in weight lost or gained
  • The strategy for monitoring the patient's response to the intervention and adjusting the intervention as necessary
  • The patient's prognosis and likely clinical course

Document the resolution of the ANS episode. Ultimately, either the patient's weight will stabilize or the lack of response will indicate an unavoidable condition. (See Step 13.) The progress note or discharge summary should include a synopsis of the assessment, therapeutic plan, and outcome. If the patient's weight stabilizes at a level not considered to be a healthy body weight, subsequent interventions may be considered but are not part of this guideline.

Monitoring

The steps involved in recognizing, assessing, and treating ANS may take place over several months. For this reason, it is recommended that one practitioner, such as a registered dietitian, dietetic technician, or registered nurse, be responsible for tracking the process and its resolution for each patient who triggers an ANS evaluation. At the facility level, the quality assurance (QA) committee or an ANS oversight committee should be responsible for ensuring the continuity of the recognition, assessment, treatment, and monitoring phases through a program of continuous quality improvement.

Step 23

Monitor the effectiveness of treatment interventions.

Weight stabilization is the primary endpoint. If ANS persists, reconsideration of the treatment plan should be documented at least monthly. When the ANS episode is resolved, the causes, interventions, and outcome should be summarized in the patient's record.

Step 24

Monitor all patients regularly to identify ANS as early as possible.

Document the findings of periodic re-evaluations in the patient's chart.

  • Following the admission evaluation, weigh the patient weekly for the first 4 weeks. If weight is stable, weigh at least monthly thereafter. For the most accurate results, always weigh the patient on the same scale, at the same time of day (preferably in the morning before breakfast), and with lightweight clothing or shoes. (See Step 1.)
  • Implement ongoing surveillance for the ANS criteria. (See Step 3.)
  • If MDS data are used as a monitoring tool, complete the MDS quarterly and with every change in condition, and record the findings in the patient's chart as a distinct entry.
  • Review advance directives annually as well as whenever a patient's clinical status changes to a degree sufficient to prompt an MDS re-evaluation. In discussions with patients and families about advance directives, ensure that preferences concerning nutritional interventions are addressed and that the care plan is updated to reflect such changes.
  • If baseline laboratory values (e.g., albumin) would be helpful in monitoring or setting care goals, consider checking those values annually or on a predetermined schedule of a different frequency that is supported by the practitioner in his or her progress note documentation.

Step 25

Monitor to ensure that each ANS risk factor identified in the admission evaluation is addressed (see Step 2).

Step 26

Monitor the incidence and prevalence of ANS in the facility.

The frequency with which the ANS criteria in Step 3 initiate an assessment can be used as an indicator of both the severity of illness among recent admissions and the quality of the facility's ANS prevention programs.

Step 27

Monitor the assessment process (see Steps 4-14).

The ANS oversight or Quality Assurance committee should establish a mechanism for tracking the assessment process when a patient triggers an evaluation for ANS.

See the appendix of the original guideline document for a weight-loss evaluation and intervention checklist.

Clinical Algorithm(s)

An algorithm is provided in the original guideline document for the recognition, assessment, treatment, and monitoring of altered nutritional status (ANS) in the long-term care setting.

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of evidence supporting the recommendations is not specifically stated.

The guideline was developed by an interdisciplinary work group using a process that combined evidence- and consensus-based approaches. Because scientific research in the long-term care population is limited, many recommendations are based on the expert opinion of practitioners in the field.

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits
  • Appropriate evaluation and management of nursing home residents who are at risk for or who have experienced a significant change in weight
  • Weight stabilization in patients who have altered nutritional status (ANS)
  • Prevention of altered nutritional status in patients at risk
  • Improved quality of care delivered to patients in long-term care settings
Potential Harms

Risks of Feeding Tube Insertion

Insertion of a feeding tube may cause diarrhea, abdominal pain, and local complications and may increase the risk of aspiration. As many as 40% of deaths related to tube feeding result from aspiration pneumonia; aspiration occurs in 44% of patients with nasogastric tubes and in 56% of patients with percutaneous gastric (PEG) tubes in long-term care settings.

Appetite Stimulants

  • Administration of megestrol acetate to elderly malnourished long-term care patients resulted in mild weight gain but was associated with a variety of side effects, including congestive heart failure, delirium, deep venous thrombosis, edema, and megacolon.
  • Metoclopramide may result in dystonic reactions and worsening of parkinsonian symptoms.
  • Adverse effects of dronabinol include euphoria, fatigue, and somnolence.

Qualifying Statements

Qualifying Statements
  • This clinical practice guideline is provided for discussion and educational purposes only and should not be used or in any way relied upon without consultation with and supervision of a qualified physician based on the case history and medical condition of a particular patient. The American Medical Directors Association (AMDA), its heirs, executors, administrators, successors, and assigns hereby disclaim any and all liability for damages of whatever kind resulting from the use, negligent or otherwise, of this clinical practice guideline.
  • The utilization of AMDA's Clinical Practice Guideline does not preclude compliance with State and Federal regulation as well as facility policies and procedures. They are not substitutes for the experience and judgment of clinicians and caregivers. The Clinical Practice Guidelines are not to be considered as standards of care but are developed to enhance the clinicians' ability to practice.
  • The corporate supporters of this guideline provided funding without condition of product use, formulary status or purchasing commitment.
  • Long-term care facilities care for a variety of individuals, including younger patients with chronic diseases and disabilities, short-stay patients needing postacute care, and very old and frail individuals suffering from multiple comorbidities. When a workup or treatment is suggested, it is crucial to consider if such a step is appropriate for a specific individual. A workup may not be indicated if the patient has a terminal or end-stage condition, if it would not change the management course, if the burden of the workup is greater than the potential benefit, or if the patient or his or her proxy would refuse treatment. It is important to carefully document in the patient's medical record the reasons for decisions not to treat or perform a workup or for choosing one treatment approach over another.

Implementation of the Guideline

Description of Implementation Strategy

The implementation of this clinical practice guideline (CPG) is outlined in four phases. Each phase presents a series of steps, which should be carried out in the process of implementing the practices presented in this guideline. Each phase is summarized below.

  1. Recognition
    • Define the area of improvement and determine if there is a CPG available for the defined area. Then evaluate the pertinence and feasibility of implementing the CPG.
  2. Assessment
    • Define the functions necessary for implementation and then educate and train staff. Assess and document performance and outcome indicators and then develop a system to measure outcomes.
  3. Implementation
    • Identify and document how each step of the CPG will be carried out and develop an implementation timetable.
    • Identify individual responsible for each step of the CPG.
    • Identify support systems that impact the direct care.
    • Educate and train appropriate individuals in specific CPG implementation and then implement the CPG.
  4. Monitoring
    • Evaluate performance based on relevant indicators and identify areas for improvement.
    • Evaluate the predefined performance measures and obtain and provide feedback.

As is the case with the other CPGs in the American Medical Directors Association (AMDA) series, implementation of this guideline requires a long-term, facility-wide commitment to reviewing and improving care processes. Many of the recommended initial interventions address the eating environment and food presentation, individualization of the diet to meet personal preferences and self-feeding ability, and feeding programs that involve staff, family members or substitute decision makers, and volunteers.

Facilities should customize the implementation of this guideline in accordance with their own circumstances. Several facility‑wide changes in policy and procedures should be considered in preparation for clinical implementation. For example, environmental changes to the dining room setting or service routines may be warranted. The recommendation to individualize meal plans presents challenges for the dietary and nursing staff. Congregate meals and assisted dining programs involving family members and volunteers may require special training and supervision. Appropriate members of the interdisciplinary team should be identified as responsible for each step of the assessment and care delivery process when a patient's condition triggers an altered nutritional status (ANS) evaluation.

It may be helpful to establish a facility-wide ANS oversight committee to develop procedures that ensure proper performance of all activities, the foundations on which clinical decisions are based, and the methods used to explain options to patients who have or are at risk for ANS and their families. This committee may include representatives of most health care disciplines as well as administrative staff. Another important responsibility is the initiation of preventive measures that may reduce the incidence of ANS. Such interventions may include avoiding the use of medications that may cause weight loss, identifying and treating depression, minimizing the use of therapeutic diets, providing assistance to patients who are not able to eat on their own, and modifying meals to match patients' eating preferences.

Note that it may take several weeks for the effects of nutritional intervention to be detected. Patient characteristics, the type of intervention, and the method used (e.g., albumin levels, weight) are among the factors that play a role in ascertaining treatment effectiveness.

Finally, this guideline recognizes that failure to identify or to correct a remediable cause of weight loss can have profound implications for the patient's prognosis and the facility's regulatory and legal liability. It is essential to clearly define unavoidable clinical decline and include palliative and end-of-life care as part of the facility's spectrum of clinical responsibilities.

Implementation Tools
Chart Documentation/Checklists/Forms
Clinical Algorithm
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
End of Life Care
Getting Better
Living with Illness
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
American Medical Directors Association (AMDA). Altered nutritional status in the long-term care setting. Columbia (MD): American Medical Directors Association (AMDA); 2010. 35 p. [71 references]
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2001 (revised 2010)
Guideline Developer(s)
American Medical Directors Association - Professional Association
Guideline Developer Comment

Organizational participants included:

  • American Association of Homes and Services for the Aging
  • American College of Health Care Administrators
  • American Geriatrics Society
  • American Health Care Association
  • American Society of Consultant Pharmacists
  • Gerontological Advanced Practice Nurses Association
  • National Association of Directors of Nursing Administration in Long-Term Care
  • National Association of Health Care Assistants
Source(s) of Funding

American Medical Directors Association

Abbot Nutrition was a corporate sponsor of this guideline.

Guideline Committee

Clinical Practice Guideline Steering Committee

Composition of Group That Authored the Guideline

Charles Cefalu, MD, MS, Clinical Practice Committee Chair

Hosam Kamel, MD, CMD, CPG Chair

Steering Committee Members: Charles Cefalu, MD, MS (Chair); Sherrie Dornberger, RNC, CDONA, FDONA; Sandra Fitzler, RN; Marianna Grachek, MSN CNHA CALA; Joseph Gruber, RPh, FASCP, CGP; Susan M. Levy, MD, CMD; Evvie F. Munley; Jonathan Musher, MD, CMD; Barbara Resnick, PhD, CRNP; William Simonson, PharmD, FASCP, CGP

Original Panel Members: *George Taler, MD, CMD (Chair); *Mary Pat Rapp, MSN, RN, Co-chair; Nichole Brandt, PharmD, CGP; Wanda Bonnel, PhD, ARNP; Kelly Carnaggio, RN, LD; *Charles Cefalu, MD, MS; Morris Kutner, MD, CMD; Lin Nyce, RD; Carlene Russell, RD, LD, FADA; Roger Shewmake, PhD, LN; Tom Tomlinson, PhD; Connie Trendel, CAN; Deidre Trent, PhD; Leslie Wooldridge, MSN, RNCS, GNP

Contributors to update: Hosam Kamel, MD, CMD (Chair); *Charles Cefalu, MD, MS, (CPG Project Chair); Judith L. Beizer, PharmD, CGP, FASCP; Norda Bellantoni, RN, CNHA, CALA, CAS; Gwendolen Buhr, MD, MHS, CMD; Cecily Byrne, MS, RD, LDN; Charles A. Crecelius, MD, PhD, CMD; Suzanne Cryst, RD, CSG, LD; Tom Edmondson, MD, CMD; Carol Elliott, RD, LDN; Sharon McCauley, MS, MBA, RD, LDN, FADA; Lynn Carpenter Moore, RD, LD; Kathleen Niedert, PhD, MBA, RD, CSG, LD, FADA; Albert Riddle, MD, CMD; Linda Roberts, MS, RD; William Smucker, MD, CMD; Barney Spivack, MD, CMD; Peter Winn, MD, CMD

*Steering Committee Member

Technical Writer: Caroline G. Polk

AMDA Staff: Jacqueline Vance, RN, C. CDONA/LTC, CPG Project Manager, Director of Clinical Affairs

Financial Disclosures/Conflicts of Interest

All contributors must submit an Accreditation Council for Continuing Medical Education (ACCME) approved disclosure form prior to being accepted as a volunteer member of the guideline workgroup. This disclosure form is reviewed by the chair of the American Medical Directors Association (AMDA) Clinical Practice Committee. If any conflicts are perceived, that person is not accepted to be part of the workgroup.

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: American Medical Directors Association (AMDA). Altered nutritional status. Columbia (MD): American Medical Directors Association (AMDA); 2001. 32 p.

Guideline Availability

Electronic copies: Not available at this time.

Print copies: Available from the American Medical Directors Association, 10480 Little Patuxent Pkwy, Suite 760, Columbia, MD 21044. Telephone: (800) 876-2632 or (410) 740-9743; Fax (410) 740-4572. Web site: www.amda.com External Web Site Policy

Availability of Companion Documents

The appendix of the original guideline document contains a Weight Loss Evaluation and Intervention Checklist.

A checklist for medications that may be associated with altered nutrition status is included as Table 5 in the original guideline document.

Patient Resources

None available

NGC Status

This summary was completed by ECRI on December 3, 2002. The information was verified by the guideline developer on December 10, 2002. This summary was updated by ECRI on August 15, 2005, following the U.S. Food and Drug Administration advisory on antidepressant medications. This summary was updated by ECRI Institute on November 2, 2007, following the U.S. Food and Drug Administration advisory on Antidepressant drugs. This NGC summary was updated by ECRI Institute on October 4, 2011. The updated information was verified by the guideline developer on November 29, 2011.

Copyright Statement

This NGC summary is based on the original guideline, which is copyrighted by the American Medical Directors Association (AMDA) and the American Health Care Association. Written permission from AMDA must be obtained to duplicate or disseminate information from the original guideline. For more information, contact AMDA at (410) 740-9743.

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