Does One Size Ever Fit All in Long-Term Care?

Long-term care (LTC) settings provide residence to a wide variety of patients, from those with cognitive impairments, to those with physical challenges, to those with both types of deficits. And even when patients are admitted to the nursing home for the same type of impairment, there are different backgrounds, medical histories, pharmacologic regimens, support networks, capabilities, preferences, and other factors to consider. That’s why an individualized approach to care for most health issues and concerns is paramount. So is there ever a time when a one-size-fits-all approach can work in this setting? The articles in this month’s issue of Annals of Long-Term Care: Clinical Care and Aging^® (ALTC) help shed some light on this question.

In our first article, “Managing Obesity in Long-Term Care”, the second article in our nutrition series, the author discusses the growing problem of obesity among the nursing home population. Because obesity is considered a health risk factor that increases a patient’s odds of developing diseases and reduces quality of life, it may be tempting to put all obese residents on a diet, especially now that the American Medical Association has classified obesity as a disease. However, implementing weight loss programs across the board for all obese LTC residents may pose risks as well. As the author notes, obesity may provide health benefits for some older institutionalized patients, so the key is to select the patients for whom weight loss is appropriate and desirable and then tailor the interventions accordingly. For most patients, a regular diet with a few modifications to facilitate slow weight loss is ideal, and physical activities should be tailored to the abilities and goals of the resident. This article emphasizes that the presence of obesity should not automatically trigger a diet prescription.

In our second article, “Prevalence of Foot Problems in Nursing Home Residents With Diabetes Stratified by Dementia Diagnosis”, the authors examined the prevalence of foot problems in residents with diabetes at three Florida nursing homes, whether there were any differences in prevalence with regard to a patient’s cognitive status, and how staff documented these problems. The authors found that 70% of residents had some type of foot problem, with 38% of residents with dementia having significant foot problems. They also found that although all patients received foot assessments upon nursing home admission and at each readmission, there was no documentation indicating the use of a monofilament examination and a tuning fork assessment, which are the strategies endorsed by the American Diabetes Association (ADA). They also found no documentation regarding patient education initiatives despite the ADA recommending that all patients receive foot care education. The authors note that the ADA’s education recommendation may be difficult to implement in LTC, as there can be considerable differences in residents’ cognitive and physical abilities. As this article indicates, although all patients should receive regular, well-documented foot assessments, interventions and education need to be individualized to the resident.

In our final article, “Vitamin D and Calcium Recommendations: Making Sense of the Hype and the Reality” ALTC board member Eric Tangalos, MD, CMD, discusses the implications of the US Preventive Services Task Force statement earlier this year recommending against the use of more than 400 IU of vitamin D₃ and more than 1000 mg of calcium for the primary prevention of fractures in postmenopausal women. Although calcium and vitamin D were routinely administered together for this purpose, Dr. Tangalos notes that staff at his facility are trained to consider and administer each supplement separately. He notes that this improves patient compliance and reduces the risk of oversupplementation. He explains that all patients at his facility receive vitamin D as a part of the facility’s falls prevention program, and calcium is administered on an individualized basis only when warranted. As this interview demonstrates, certain preemptive strategies may warrant a one-size-fits-all approach, but physicians need to carefully consider when such strategies are appropriate.

Finally, I would like to tell you about some new features we have added to the ALTC Website. First, there is now a slider at the top of the homepage that highlights LTC news and human-interest stories. We recognize that there are a lot of stories in nursing homes that go beyond simply providing good medical care and we wanted a place to highlight these for you. Second, we added a Conference Coverage option to the top navigation bar, enabling you to easily access news from a variety of professional conferences. Third, we have added additional bloggers, including our new board member Ilene Warner-Maron, PhD, assistant professor, Department of Interdisciplinary Health Services, St. Joseph’s University, and president, Institute for Continuing Education and Research. We are delighted to welcome Dr. Warner-Maron to our board, and we hope these new features will give you reason to visit us more frequently online.

As always, we welcome your feedback on the articles in this issue of ALTC. Responses can be sent to our associate editor, Allison Musante, at amusante@hmpcommunications.com, or you can comment directly online.

Thank you for reading!