Article

Position of the American Dietetic Association: Liberalization of the diet prescription improves quality of life for older adults in long-term care.

Western Home Communities, Cedar Falls, IA, USA.
Journal of the American Dietetic Association (Impact Factor: 3.92). 01/2006; 105(12):1955-65.
Source: PubMed

ABSTRACT It is the position of the American Dietetic Association (ADA) that the quality of life and nutritional status of older residents in long-term care facilities may be enhanced by liberalization of the diet prescription. The Association advocates the use of qualified dietetics professionals to assess and evaluate the need for medical nutrition therapy according to each person's individual medical condition, needs, desires, and rights. In 2003, ADA designated aging as its second "emerging" area. Nutrition care in long-term settings must meet two goals: maintenance of health and promotion of quality of life. The Nutrition Care Process includes assessment of nutritional status through development of an individualized nutrition intervention plan. Medical nutrition therapy must balance medical needs and individual desires and maintain quality of life. The recent paradigm shift from restrictive institutions to vibrant communities for older adults requires dietetics professionals to be open-minded when assessing risks vs benefits of therapeutic diets, especially for frail older adults. Food is an essential component of quality of life; an unacceptable or unpalatable diet can lead to poor food and fluid intake, resulting in weight loss and undernutrition and a spiral of negative health effects. Facilities are adopting new attitudes toward providing care. "Person-centered" or "resident-centered care" involves residents in decisions about schedules, menus, and dining locations. Allowing residents to participate in diet-related decisions can provide nutrient needs, allow alterations contingent on medical conditions, and simultaneously increase the desire to eat and enjoyment of food, thus decreasing the risks of weight loss, undernutrition, and other potential negative effects of poor nutrition and hydration.

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    ABSTRACT: Background: Malnutrition is a common problem for residents of nursing homes and long-term care hospitals. It has a negative influence on elderly residents and patients health and quality of life. Nutritional care seems to have a positive effect on elderly individuals nutritional status and well-being. Studies of Finnish elderly people s nutrition and nutritional care in institutions are scarce. Objectives: The primary aim was to investigate the nutritional status and its associated factors of elderly nursing home residents and long-term care patients in Finland. In particular, to find out, if the nursing or nutritional care factors are associated with the nutritional status, and how do carers and nurses recognize malnutrition. A further aim was to assess the energy and nutrient intake of the residents of dementia wards. A final objective was to find out, if the nutrition training of professionals leads to changes in their knowledge and further translate into better nutrition for the aged residents of dementia wards. Subjects and methods: The residents (n=2114) and patients (n=1043) nutritional status was assessed in all studies using the Mini Nutritional Assessment test (MNA). Information was gathered in a questionnaire on residents and patients daily routines providing nutritional care. Residents energy and nutrient intake (n=23; n=21) in dementia wards were determined over three days by the precise weighing method. Constructive learning theory was the basis for educating the professionals (n=28). A half-structured questionnaire was used to assess professionals learning. Studies I-IV were cross-sectional studies whereas study V was an intervention study. Results: Malnutrition was common among elderly residents and patients living in nursing homes and hospitals in Finland. According to the MNA, 11% to 57% of the studied elderly people suffered from malnutrition, and 40-89% were at risk of malnutrition, whereas only 0-16% had a good nutritional status. Resident- and patient-related factors such as dementia, impaired ADL (Activities of Daily Living), swallowing difficulties and constipation mainly explained the malnutrition, but also some nutritional care related factors, such as eating less than half of the offered food portion and not receiving snacks were also related to malnutrition. The intake of energy and some nutrients by the residents of dementia wards were lower than those recommended, although the offered food contained enough energy and nutrients. The proportion of residents receiving vitamin D supplementation was low, although there is a recommendation and known benefits for the adequate intake of vitamin D. Nurses recognized malnutrition poorly, only one in four (26.7%) of the actual cases. Keeping and analysing food diaries and reflecting on nutritional issues in small group discussions were effective training methods for professionals. The nutrition education of professionals had a positive impact on the energy and protein intake, BMIs, and the MNA scores of some residents in dementia wards. Conclusions: Malnutrition was common among elderly residents and patients living in nursing homes and hospitals in Finland. Although residents- and patient related factors mainly explained malnutrition, nurses recognized malnutrition poorly and nutritional care possibilities were in minor use. Professionals nutrition education had a positive impact on the nutrition of elderly residents. Further studies describing successful nutritional care and nutrition education of professionals are needed. Ikääntyneiden ihmisten ravitsemus ja ravitsemushoito suomalaisissa vanhainkodeissa ja sairaaloissa ETM Merja Suomisen ravitsemustieteen väitöskirjan Nutrition and Nutritional Care of Elderly People in Finnish Nursing Homes and Hospitals (Ikääntyneiden ihmisten ravitsemus ja ravitsemushoito suomalaisissa vanhainkodeissa ja sairaaloissa) tarkastustilaisuus on Helsingin Yliopistomuseon Arppeanum-juhlasalissa (osoite Snellmanninkatu 3) perjantaina 30.11.2007 klo 12. Vastaväittäjänä toimii professori Cornel Sieber Erlangen-Nürnbergin yliopistosta ja kustoksena professori Marja Mutanen. Ravitsemusongelmat tavallisia Tutkimuksen tarkoituksena oli selvittää vahainkodeissa ja sairaaloissa asuvien ikääntyneiden ihmisten ravitsemustilaa ja siihen yhteydessä olevia tekijöitä Suomessa. Väitöskirja koostuu viidestä osatutkimuksesta, joista neljä oli poikkileikkaustutkimuksia ja yksi interventiotutkimus. Ravitsemukseen liittyvät ongelmat ovat tavallisia vanhainkodeissa ja pitkäaikaissairaaloissa asuvilla. Virheravitsemus vaikuttaa negatiivisesti iäkkäiden vanhainkotiasukkaiden ja sairaalapotilaiden terveyteen ja elämän laatuun. Ravitsemushoidolla näyttää olevan myönteisiä vaikutuksia ikääntyneiden ravitsemustilaan ja hyvinvointiin. Tosin Suomessa ikääntyneiden ravitsemusta ja ravitsemushoidon mahdollisuuksia on tutkittu melko vähän, sanoo Merja Suominen. Tutkimuksiin osallistui asukkaita vanhainkodeista ja dementiaosastoilta sekä iäkkäitä sairaalapotilaita. Mukana oli 2114 vanhainkotiasukasta ja 1043 sairaalapotilasta. Heidän ravitsemustilansa arvioitiin MNA-testillä (Mini Nutritional Assessment). Kyselylomakkeella kerättiin tietoja asukkaiden ja potilaiden ravitsemukseen liittyvistä päivärutiineista. Dementiakotien asukkaille tehtiin omat tutkimukset (n=23; n=21), jossa energian ja ravintoaineiden saantia arvioitiin kolmen päivän ruokapäiväkirjan avulla. Hoitajille ja ruokapalveluhenkilöstölle annettiin ravitsemuskoulutusta, joka pohjautui konstruktiiviseen oppimisteoriaan. Lisäksi hoitajien ja ruokapalveluhenkilöstön (n=28) oppimista arvioitiin puolistrukturoidulla kyselylomakkeella. Virhe- ja aliravitsemus tunnistetaan huonosti Tutkimuksen mukaan virhe- ja aliravitsemus oli yleistä vanhainkodeissa ja sairaaloissa. MNA-testin mukaan 11 57 % tutkituista kärsi virhe- tai aliravitsemuksesta ja 40 89 %:lla riski virheravitsemukselle oli kasvanut. Vain 0 16 %:lla ravitsemustila oli hyvä. Dementia, heikentynyt toimintakyky, nielemisvaikeudet ja ummetus pääasiassa selittivät aliravitsemusta. Myös ravitsemushoitoon liittyvät tekijät, kuten syöminen vain puolet tai vähemmän tarjotusta ruoka-annoksesta ja välipalojen syömättömyys olivat yhteydessä virhe- ja aliravitsemukseen. Hoitajat tunnistivat aliravitsemuksen huonosti, vain noin neljäsosa (26,7 %) tapauksista tunnistettiin. Dementiakotien asukkaiden energian ja joidenkin ravintoaineiden saanti oli suosituksia alhaisempaa, vaikka tarjottu ruoka sisälsi riittävästi energiaa ja ravintoaineita. D-vitamiinilisää saavien vanhainkotiasukkaiden osuus oli pieni, vaikka D-vitamiinilisän käytöstä on olemassa suositukset ja sen hyöty on selvästi osoitettu, Suominen toteaa. Hoitajien ravitsemuskoulutuksesta hyötyä Hoito- ja ruokapalveluhenkilökunnan ravitsemuskoulutuksella oli myönteinen vaikutus iäkkäisiin dementiakodin asukkaisiin. Ruokapäiväkirjojen pitäminen ja niiden analysointi sekä ravitsemusasioista keskustelu pienryhmissä olivat hoitajien mielestä tehokkaita oppimistapoja. Hoitajien ravitsemuskoulutuksella oli positiivinen vaikutus dementiaosastoilla, mm. joidenkin asukkaiden energian ja proteiinin saanti, painoindeksi ja MNA testin tulos paranivat. Sairaudet ja heikentynyt toimintakyky selittivät pääasiassa huonoa ravitsemustilaa vanhainkodeissa ja pitkäaikaissairaaloissa, mutta puutteita on myös siinä, että hoitajat tunnistivat aliravitsemuksen huonosti ja ravitsemushoidon mahdollisuuksia käytettiin vain vähän. Lisätutkimukset ravitsemushoidon ja hoitohenkilökunnan ravitsemuskoulutuksen vaikuttavuudesta ovat Merja Suomisen mukaan tarpeellisia.