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.
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)
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
- Medication use
- Therapeutic diets
- Nausea, vomiting, or diarrhea
- Fluid retention and edema
- Underlying infection
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)
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
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.
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.
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.
For patients whose food intake is inadequate: Screen for social and environmental factors, dietary restrictions, and food preferences.
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.
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.
Screen patients who gain weight for conditions related to fluid retention.
Tier II Assessment
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.
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).
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.
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 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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Monitor to ensure that each ANS risk factor identified in the admission evaluation is addressed (see Step 2).
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.
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.