Advancing Nutritional Care for Older Adults

In the older adult population, the consequences of malnutrition can have a major impact on health, such as unintended weight loss, sarcopenia, frailty, and delayed healing of pressure ulcers. Serving healthful, nourishing meals is not always an easy task in long-term care settings, where staff are contending with food–medication interactions, anorexia, gastrointestinal issues, depression, chronic diseases, poor dentition, difficulty chewing and swallowing, and other issues affecting proper nutritional absorption. Overcoming these barriers is becoming increasingly important, as the literature continues to strengthen the association between good nutrition and overall health in older adults.   

There is major potential in the year 2014 for improving the quality of nutritional care in long-term care settings. In particular, updated guidelines on the role of nutrition in preventing and treating pressure ulcers are in the pipeline, and the Centers for Medicare & Medicaid Services (CMS) issued a new rule giving greater autonomy to registered dietitians.

Annals of Long-Term Care^® (ALTC) had the opportunity to discuss these two developments and other popular topics in nutritional care with Becky Dorner, RDN, LD, FAND. Dorner is president of Becky Dorner & Associates, Inc, which offers continuing education and publications for professionals who provide nutrition care to older adults, and president of Nutrition Consulting Services, Inc, which has provided food and nutrition consulting services to healthcare facilities since 1983. She is also the chair of the Council on Future Practice for the Academy of Nutrition and Dietetics.

ALTC: As you know, the National Pressure Ulcer Advisory Panel (NPUAP) is in the process of revising its clinical practice guidelines for preventing and treating pressure ulcers, with the goal of releasing an updated set later in 2014. What are the current clinical guidelines with regard to nutrition’s role in pressure ulcer prevention and treatment, and what do you expect we’ll see in the revised guidelines?

Dorner: Nutrition and hydration have a well-documented role in pressure ulcer prevention and treatment. Adequate calories, protein, fluids, and nutrients are all needed to prevent and/or heal pressure ulcers. The NPUAP published a white paper on nutrition (I was a co-author)¹ as well as clinical guidelines that include detailed information regarding nutrition for the prevention and treatment of pressure ulcers. The currently published 2009 guidelines recommend 30 to 35 calories per kilogram of body weight, 1.25 to 1.5 grams of protein per kilogram of body weight, and adequate fluids to maintain hydration (estimated 1 mL per calorie consumed or 30 mL of fluid per kilogram of body weight), along with a multivitamin/mineral supplement if deficiencies are suspected or confirmed. Much more detail on nutrition is available in the guidelines. I expect that the new guidelines will continue to emphasize nutrition as a critical factor in the prevention and treatment of pressure ulcers.

The term nutraceutical seems to be the buzzword of the moment when talking about geriatric nutrition. What is a nutraceutical? Is it the same as a dietary supplement?

The use of nutraceuticals is not really new although the term may be more popular now than in previous years. The term “nutraceutical” was coined in 1989 by Stephen L. DeFelice to combine the words “nutrition” and “pharmaceutical.” Nutraceuticals refer to a range of foods and supplements from diet and processed foods to dietary supplements, herbal products and isolated nutrients. Nutraceuticals have been used for years in the form of vitamin/mineral supplements and individual vitamins or minerals (vitamin D, vitamin B₁₂, calcium, iron). There are numerous situations that may require a nutraceutical, including vitamin or mineral deficiencies, inadequate calorie or protein intake, and inadequate potassium intake, to name a few.

In the United States, the term actually has no meaning under regulatory law.² These items are classified as one of the following under US regulations and treated accordingly: a food, a food ingredient, a dietary supplement, or a drug.³ Nutraceuticals often carry claims to prevent certain health problems, improve health, or delay aging; of course, claims must be within the legal limitations for the category as noted above.

The US Dietary Supplement Health and Education Act (DSHEA) of 1994 defined a dietary supplement as a product taken by mouth that contains a “dietary ingredient” intended to supplement the diet. This may include: vitamins, minerals, herbs, botanicals, amino acids, enzymes, organ tissues, glandulars, and metabolites. Dietary supplements can also be extracts or concentrates in the form of tablets, capsules, soft gels, gel caps, liquids, or powders. DSHEA categorizes all dietary supplements under the general umbrella of “foods” and requires that they be labeled as a dietary supplement.⁴

Dietary supplements do not need approval from the US Food and Drug Administration unless it is a new dietary ingredient, in which case there must be premarket review for safety data required by law.  The manufacturer is responsible for determining that the product is safe and that any claims made about the product is substantiated by adequate evidence to show that they are not false or misleading.

Functional foods also fall under the “nutraceutical” category. These are foods that have been enriched or fortified so that people can consume that food and not have to take a dietary supplement in pill form. Examples include milk with added vitamin A and D, or cereals with added iron.

Do you personally recommend the use of any of nutraceuticals for older adults?

Yes, I do recommend the use of certain nutraceuticals. However, before recommending anything, a comprehensive nutrition assessment should be completed by a registered dietitian nutritionist (RDN) to determine the most appropriate individualized interventions for each person. This is especially important for frail older adults with multiple comorbidities. Choosing the right interventions based on the person’s medical history and nutritional status, balanced with a review of their current food/fluid intake, preferences, and tolerances is the only way to effectively intervene to prevent or correct nutritional deficiencies and malnutrition.

Consuming probiotics and prebiotics is another nutritional strategy that is not new, but there has been a renewed interest in the potential benefits of these agents for older adults. Please explain the difference between a probiotic and a prebiotic.

Probiotics are “friendly” bacteria that may aid in digestion and protect from harmful bacteria, similar to what the existing good bacteria in the body do. Prebiotics are naturally occurring nondigestible food ingredients that fuel probiotics. They have been shown to improve digestive function and the intestinal environment and can complement probiotics. Prebiotics can be found in foods like artichokes, asparagus, garlic, oats, onion, soybeans, and wheat. Other prebiotics include fructooligosaccharides, which are not digested in the gastrointestinal tract but are fermented in the colon.

Combining prebiotics with probiotics creates a symbiotic product, which contains the live bacteria (cultures) and the food they need to thrive. Foods such as yogurt with live active cultures or kefir, which are fermented dairy products, are examples of symbiotic products.

Prebiotics, probiotics, and symbiotics are good for gut health. However, despite the fact that there have been some positive animal studies, there is not enough evidence to recommend prebiotics for prevention or treatment of diarrhea in humans.⁵ Well-conducted human trials are needed to confirm prebiotic effects.

What does the evidence show so far regarding the potential of probiotics and prebiotics?

Probiotics may assist the body to reestablish naturally occurring gut flora. In addition, they may offset side effects of antibiotics (ie, gas, cramping, diarrhea), and help to strengthen the immune system. They have been found to be helpful in reducing symptoms for people with antibiotic-associated diarrhea (AAD)⁶ and may be helpful in controlling symptoms for people with Clostridium difficile by preventing growth of the bacteria. Lactobacillus is a type of probiotic that may be effective in preventing C difficile relapse by inhibiting regrowth of the bacteria. Lactobacillus is found in yogurt with active cultures and kefir.

Some probiotics have been clinically proven to be effective against C difficile and have been formulated into tablets, powders, capsules, and beverages. There is controversy in the scientific literature regarding the effectiveness and efficacy of probiotics for diarrhea management. Because there is a lack of standardization of products as well as a lack of strong research on the efficacy of probiotics, they are not recommended for prevention of primary C difficile infection.^7-10

Based on a meta-analysis of randomized controlled trials, in 2005 the Journal of Family Practice recommended that patients on antibiotics should also take probiotics due to their effectiveness for the prevention and treatment of AAD.¹¹ However, research on probiotics for prevention and treatment of AAD and C difficile–associated diarrhea is conflicting, and it is unclear which, if any, probiotic therapy may work with which strain of bacteria and type of diarrhea.¹² There is limited evidence that two probiotics, Lactobacillus rhamnosus GG and Saccharomyces boulardii, decrease the incidence of AAD, and further research is needed to determine which probiotics have the greatest efficacy for patients on specific antibiotics.¹³

What are some of the considerations before starting older adults on probiotics or prebiotics?

Evidence suggests that use of probiotic therapy is probably not harmful to most patients. Probiotics typically have few side effects, and these effects tend to be mild, such as gas or bloating. However, the data on safety, especially long-term safety, is limited, and the concern is that the risk of serious side effects may be greater in people who have underlying health conditions.¹⁴ One more note of caution: patients who are lactose intolerant should not receive Lactobacillus preparations.¹⁵

We know much about how food can enhance, delay, or decrease drug absorption. Since the majority of older adults residing in long-term care settings are taking multiple medications, what are some of the most important adverse food–drug interactions that long-term care providers should be aware of?

Any food–medication interaction that is therapeutically important is cause for concern. From a nutrition standpoint, we want to ensure optimal nutritional status. From a medical standpoint, we want to be sure the drug achieves its intended effect while avoiding complications and adverse side effects. If we can identify food–medications interactions early on, we can prevent major negative consequences. Healthcare professionals should ensure medications are given per manufacturer’s directions (ie, given on an empty stomach vs after eating, avoidance of certain foods with certain medications) for best tolerance and absorption of medications. For example, thyroid hormone is best absorbed on an empty stomach when given with 8 ounces of water. It should be given separately and with 4 hours difference from iron, calcium, or magnesium supplementation. Soy products, high-fiber foods, and walnuts decrease the absorption of thyroid hormone.

In general, healthcare providers need to watch for symptoms such as anorexia, nausea, constipation, diarrhea, and any other interactions that impede food and fluid intake. A major concern in frail older adults is to avoid unintended weight loss, so monitoring food and fluid intake as well as obtaining accurate and timely weight measurements on a regular schedule becomes extremely important. In addition, fluid fluctuations should be monitored, especially in those people taking diuretics, such as hydrochlorothiazide, furosemide, and other similar medications. Fluid shifts can be a major concern especially if they lead to dehydration, overhydration, or electrolyte imbalances, all of which can cause cognitive changes and other serious complications.

For people on enteral feedings, there are additional concerns, such as potential for clogged tubes and decreased absorption of medications. For example, potassium chloride elixir and ferrous sulfate (iron) elixir can cause clumping of enteral products, which can clog feeding tubes. Phenytoin absorption may decrease when phenytoin suspension is given with an enteral formula, so we need to be sure to hold feedings 2 to 4 hours before and after a phenytoin dose is administered, or give phenytoin intravenously.¹⁶

What resources do you recommend to nurses to help them minimize the risk of adverse food–drug interactions?

Dietitians work very closely with the interdisciplinary team, and we rely on the nursing staff to refer residents with nutrition risks to us. There should be a referral system in place, and for it to work correctly, nursing staff could benefit from some basic training on food–medication interactions. For daily quick reference, the Food–Medication Interactions pocket guide or software for digital devices is a great choice. Information can be found at www.foodmedinteractions.com. Monitoring for interactions is extremely important, so systems need to be in place to obtain and assess accurate and timely weights, food and fluid intake, and fluid balance, and to review laboratory values as needed to monitor for electrolyte imbalances and other potential concerns. It is extremely important to take patient complaints seriously and refer to the RDN as soon as there are symptoms that affect food/fluid intake or weight, or there are concerns about other factors that may lead to malnutrition.

On May 12, 2014, CMS issued a final rule reforming Medicare regulations that CMS has identified as “unnecessary, obsolete, or excessively burdensome on healthcare providers and suppliers.”¹⁷ The rule stipulates that RDNs can order patient diets independently, no longer requiring supervision or approval of a physician or other practitioner. This rule will become effective on July 11, 2014 and applies to RDNs working in hospitals only. But the Academy of Nutrition and Dietetics is urging CMS to issue a separate regulatory change that would apply to RDNs working in long-term care facilities.¹⁸ What do you think of this rule, and should it be applied in the long-term care setting too? 

Our goal as RDNs is to find the underlying cause of the malnutrition and to provide the most appropriate nutrition interventions to correct and/or minimize the consequences. If we can identify risks early on and intervene, we can reduce the potential complications that malnutrition may cause. Therefore, RDNs are very pleased with this new rule as it will allow more autonomy to practice at the height of their competency levels. The rule passed because CMS “believe[s] that RDs are the professionals who are best qualified to assess a patient’s nutritional status and to design and implement a nutritional treatment plan in consultation with the patient’s interdisciplinary care team.”¹⁶

This rule allows qualified dietitians or qualified nutrition professionals explicit permission to become privileged by the hospital staff to order patient diets (including nutritional supplements), order lab tests to monitor the effectiveness of dietary plans and orders, and make subsequent modifications to those diets based on the lab tests, as long as this is in accordance with state laws, including scope of practice laws. CMS notes that lab ordering “privileges for dietitians and nutrition professionals are not required or specifically allowed by this requirement, but are instead an option left to hospitals and their medical staffs to determine in consideration of relevant State law as well as any other requirements and/or incentives that CMS or other insurers might have.”¹⁶
The Academy is planning to provide members with the tools they will need to implement this new rule in the hospital setting. This includes tools for how to discuss the issue with their employers and medical staff, as well as strategies for obtaining privileges and sample policies. In addition, they plan to provide an analysis of the impact of state licensure laws and regulations on implementation. They will continue to work to extend the ability to order therapeutic diets across the continuum of care, including long-term care settings.

References

1. Dorner B, Posthauer ME, Thomas D; National Pressure Ulcer Advisory Panel. The role of nutrition in pressure ulcer prevention and treatment: National Pressure Ulcer Advisory panel white paper. Adv Skin Wound Care. 2009;22(5):212-221. www.npuap.org/wp-content/uploads/2012/03/Nutrition-White-Paper-Website-Version.pdf.
2. Labeling and nutrition. US Food and Drug Administration. www.fda.gov/Food/IngredientsPackagingLabeling/LabelingNutrition/default.htm. Updated February 27, 2014. Accessed June 5, 2014.
3. Q&A on dietary supplements. US Food and Drug Administration. www.fda.gov. Updated March 20, 2014. Accessed June 5, 2014.
4. De Vrese M, Marteau PR. Probiotics and prebiotics: effects on diarrhea. J Nutr 2007;137(3 suppl 2):803S-811S.
5. Schroeder MS. Clostridium difficile–associated diarrhea. Am Fam Physicians. 2005;71(5):921-928.
6. Cohen SH, Gerding DN, Johnson S, et al; Society for Healthcare Epidemiology of America; Infectious Diseases Society of America. Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the Society for Healthcare Epidemiology of American (SHEA) and the Infectious Diseases Society of America (IDSA). Infect Control Hosp Epidemiol. 2010;31(5):431-455.
7. Surawicz SM, Brandt LJ, Binion DG, et al. Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections. Am J Gastroenterol. 2013;108(4):478-498.
8. Guarino A, Lo Vecchio A, Canani RB. Probiotics as prevention and treatment for diarrhea. Curr Opin Gastroenterol. 2007;25(1):18-23.
9. Dendukuri N, Costa V, McGregor M, and Brophy JM. Probiotic therapy for the prevention and treatment of Clostridium difficile-associated diarrhea: a systematic review. CMAJ. 2005;173(2):167-170.
10. Rodgers B, Kirley K, Mounsey A. Prescribing an antibiotic? Pair it with probiotics. J Fam Pract. 2013;62(3):148-150.
11. Dorner B. Diet and Nutrition Care Manual. Naples, FL: Becky Dorner & Associates Inc, 2014.
12. Hempel S, Newberry SJ, Maher AR, et al. Probiotics for the prevention and treatment of antibiotic-associated diarrhea: a systematic review and meta-analysis. JAMA. 2012;307(18):1959-1969.
13. Oral probiotics: an introduction. US Department of Health and Human Services National Institutes of Health. National Center for Complementary and Alternative Medicine. https://nccam.nih.gov/health/probiotics/introduction.htm. Updated December 2012. Accessed June 3, 2014.
14. Williams NT. Probiotics. Am J Health Syst Pharm. 2010;67(6):449-458.
15. Phelps N. Management of phenytoin with enteral feeding. Ment Health Clin. 2012;2(5):13.
16. Medicare and Medicaid programs; regulatory provisions to promote efficiency, transparency, and burden reduction; part II. Federal Register. www.federalregister.gov/articles/2014/05/12/2014-10687/medicare-and-medicaid-programs-regulatory-provisions-to-promote-program-efficiency-transparency-and. Published May 12, 2014. Accessed June 5, 2014.
17. FAQs – CMS final rule related to therapeutic diet orders. Academy of Nutrition and Dietetics. www.eatright.org/HealthProfessionals/content.aspx?id=6442474904. Accessed June 5, 2014.
18. §483.35. Dietary services. Part 483: Requirements for states and long-term care facilities. Title 42: public health. Electronic Code of Federal Regulations website. https://bit.ly/LTC_FedRegulations. Updated June 4, 2014. Accessed June 6, 2014.