The Role of Registered Dietitians in Long Term Care
Everyone gets older. It’s the way of life. Some people have a plan for what they want to do or where they want to live when they retire or if they get sick, and there seems to be endless options out there. Long term care is an option that many people choose, yet it can be confusing to sort through every option. Oftentimes, questions asked about long term care facilities include “What services are offered?” and “How will I afford the care I am seeking?” (1). Because there are so many factors that play a role in long-term care, there is a large team of interdisciplinary professionals that must work together to create the highest quality of care for residents. This team is made up of doctors, physical therapists, occupational therapists, nurses, speech therapists, etc. The role of Registered Dietitians in Long Term Care is sometimes overlooked. Registered Dietitians play an integral role in maintaining the optimal standard of care for people in long term care; not only do these professionals have specialized knowledge for the nutrition needs of many disease states and allergies, but they also play a role in food preparation and menu planning, counseling patients, and administering therapeutic diets.
To best understand the role that dietitians play in long term care, it is important to understand the different types of long term care that exist in the United States. Because “long-term care” generally means helping people with medical needs or activities of daily living over a long period of time, there are different steps of long term care available according to an individual’s needs (2). There is care that can be done entirely from home, care that is entirely out of home, and many steps of care in between. Understanding the similarities and differences of these steps can clarify the essentiality of nutrition in each setting.
Home Health Care
The least aggressive form of long term care, home care, is care that can be given in a person’s home by friends or family or by a hired professional (2). This can include wound care, intravenous or nutrition therapy, helping with cooking, grocery shopping, giving medicines, etc. (2)(3). The goal of home health care is to treat an illness or injury in order to help a patient regain independence and become as self-sufficient as possible (3).
There are a wide variety of community programs available to support adults during the day. These are for patients who are able to support themselves at home, but need some extra help when it comes to some activities of daily living. Community services include adult day care, meal programs such as Meals on Wheels, community centers and much more (2). Even services such as pet food delivery, home repair services and transportation to and from appointments is available (4).
Supportive Housing Programs
The Federal Department of Housing and Urban Development (HUD) funds and develops low-cost housing to older people with low to moderate incomes. Residents live in their own apartments but receive assistance for tasks such as laundry, shopping, housekeeping, and meal preparation (2).
Assisted living is the first step of healthcare where patients are residents under 24-hour supervision, but people here live in a home-like setting (2). Residents may live in their own room or apartment, but are offered help with activities of daily living such as eating, bathing and getting dressed (5). Oftentimes recreational activities are provided in addition to housekeeping, laundry, transportation, and medical services (2).
Continuing Care Retirement Communities (CCRC)
Continuing care retirement communities incorporate a home and neighborhood type setting with all of the perks of added services, and the services may range based on what each resident needs over time (2). Many consider CCRCs to be the ideal senior living option to “age in place,” which is why living in one is so expensive (7). CCRCs bring in a combination of independent living, assisted living, and skilled nursing (6).
Nursing homes, also known as skilled nursing facilities (SNF), are the highest level of care a person can receive in long term care. They offer care to people who cannot be cared for at home or in the community; examples include people with complex or potentially serious medical problems such as infections, IV therapy, or coma care (2)(8). Many nursing homes also offer temporary care, oftentimes referred to as “respite care,” for patients after a long stay at the hospital in order to give family or friend caregivers some time off (2).
The Role of Registered Dietitians in Long Term Care and Key Factors that Affect Nutrition in Older Adults
Registered Dietitians in Long Term Care are most utilized on the clinical side to maintain patients’ nutrition status. Dietitians must help healthy patients continue to eat healthy diets, and they must also build diets from the ground up for patients that are recovering from any trauma or illness. In the older stages of life, there are many factors that affect a person’s ability or willingness to eat.
Decreased taste and loss of appetite: As we age, our taste and sense of smell decreases, so older people have a blunted appetite regulation compared to when they were younger (9). The number of taste buds we were born with begins to decrease, and the taste buds that remain begin to shrink in size (10). Many medications also decrease the ability to distinguish the taste of salty, sweet, etc. tastes and dentures make it difficult to thoroughly chew food (9)(12). This overall leads to a decreased sense of appetite as well as a loss of interest to eat. A lack of interest in eating can over time cause fatigue and malnutrition in older adults, and research shows that if an older person begins to lose their appetite, they have a higher chance of dying in the next six months (11)(13).
Financial issues: As we age, our ability to work decreases. Not being able to work can cause financial strain, and if someone has to be frugal with money, sometimes the ability to purchase nutrient-dense food, or any food at all, can fall by the wayside.
Lack of mobility: Imagine not being able to stand or walk for long periods of time, or having arthritic pain in your hands that makes it difficult to grip small items. These are common problems that older people have to deal with, and it can make it very difficult to prepare or eat food (9). If someone with these mobility problems does not have a family member or staff person to cook or help feed them, they might not eat as many times throughout the day.
Depression: Many older people deal with some stage of loneliness or depression, as their independence to do things for themselves decreases and as loved ones pass away. A person may not want to eat if they are not able to make the food themselves, or if it dredges up memories of eating with a loved one (12). The thought of eating alone is not as appetizing, so some elderly people choose not to eat. They may also forget to eat if they live by themselves and no one is around to go out to eat with or remind them to cook (9).
Nutrient absorption: Our bodies do not function as well as they did when we were younger. Because of this, as we age, nutrients are not absorbed as well, and this can lead to malnutrition or vitamin and mineral deficiencies (9). GI motility slows as we age, so corresponding constipation or diarrhea may also make it uncomfortable to eat, leading people to have less likelihood to enjoy eating (14).
Dietitians are the one to call if an older loved one in long term care seems to be struggling with getting adequate nutrition. They can discuss prescription changes with doctors, or suggest a medication that may help increase appetite. They can create an eating schedule to help patients remember to eat, or make meal plans that seem more appealing to the resident by using visually stimulating ingredients or recipes that evoke an emotional connection. By giving an older adult food choices that are smaller portions but have increased nutrient density, the adult is getting the best bang for their buck in terms of eating to their satisfaction but getting the most concentrated nutrition possible.
Registered Dietitians in Long Term Care work very closely with an interdisciplinary team to ensure optimal quality care for all adults. RDs work with Speech Language Pathologists to obtain swallow studies that help determine if a dysphagia diet is needed and which one, and they work with nurses to give specialized nutrition when nurses dictate stages of pressure ulcers or wounds. They work with gastroenterologists when feeding tubes are placed and surgeons after bariatric procedures. They work with social workers to help determine how socioeconomic factors affect an adult’s ability to eat, work with chefs to create meals that are both nutritious and delicious, and work with doctors to educate patients on how to live with common diseases such as diabetes and hypertension. All of these are simple examples of how “it takes a village” to care for each and every adult in long term care.
When an adult’s inability or unwillingness to eat becomes more serious, it may be essential to place them on a special diet. Special diets may range from dysphagia diets to enteral nutrition (feeding tubes) to total parenteral nutrition (intravenous feeding) (15).
Dysphagia Diets: Foods
Dysphagia Advanced Diet or Soft Diet (NDD3)- foods of “nearly regular” textures with the exception of very hard, sticky, or crunchy foods
Mechanical Soft (NDD2)- foods with a moist, soft texture. Meats need to be chopped or ground and vegetables need to be well cooked and easily chewed. Foods should be in small pieces with no hard, chewy, fibrous or crumbly bits and no “floppy” textures such as lettuce and raw spinach. Foods where the juice separates from the solid upon chewing, such as watermelon, are unsafe.
Pureed (NDD1)- foods that are pureed to a homogenous, cohesive, smooth texture. They should be “pudding-like” and hold its shape on a spoon, which means the food does not contain lumps, is not sticky, and will not spread out if spilled. The prongs of a fork should make a clear pattern when drawn across the surface of the puree.
Regular Diet- all foods acceptable; persons have the ability to produce saliva and chew as long as it takes for the food to form a bolus for safe swallowing; mixed textures are no problem
Dysphagia Diets: Fluids
Thin- a liquid that easily changes form and slides off of a spoon. It is the texture of water.
Nectar thick- a liquid that coats and drips off a spoon like a lightly-set gelatin, and therefore requires a little more effort to drink than thin liquid. This texture is easier to control than thin liquid and can flow through a straw.
Honey thick- a liquid that is thicker than nectar thick and flows off a spoon in a ribbon, like honey. This texture allows for a more controlled swallow and is difficult to drink through a straw.
Pudding thick- a thicker liquid that stays on spoon in a soft mass but will not hold its shape. This texture pours slowly off a spoon. (9)
Nutrition Support: Enteral Nutrition
Enteral nutrition is indicated when a person is not getting enough nutrition through oral intake alone, but the person’s gastrointestinal tract is still intact and functioning. Situations where this may be appropriate include liver failure, head/neck trauma, critical illnesses such as burns that cause high metabolic stress, prolonged anorexia etc. Enteral nutrition is not supported in situations such as intestinal obstructions, active gastrointestinal hemorrhages, or hemodynamic instability (16). Feedings are administered through a feeding tube; nasogastric (NG), nasojujenal (NG), and percutaneous endoscopic gastrostomy (PEG) tubes are the most commonly used (15).
An RD is contacted to calculate all of the patients’ nutritive needs, including calories, protein and fluid among others. A specific formula is then selected by the dietitian, and he or she decides how the feedings will be given. Continuous feeding is delivering feedings slowly throughout the day all day, whereas bolus feeding gives feedings incrementally in larger amounts. Continuous feedings are administered via gravity or a pump and is usually tolerated better than bolus feedings, but bolus feedings allow for more mobility than continuous drip feedings because there are breaks in the feedings which allow the patient to be free from the tube feeding apparatus for activities such as physical therapy. Overall, the goal of enteral nutrition is to return the patient back to a state of health where they can maintain adequate nutrition status without the need for supplemental feedings. (16)
Nutrition Support: Parenteral Nutrition
Parenteral nutrition (PN) is indicated when a person needs supplemental nutrition, but enteral nutrition cannot be used. Situations where a person may need PN include irritable bowel syndrome, cancer, short bowel syndrome, when the gut is not working enough to maintain fluids or electrolytes, or if a tube cannot be placed into the GI tract. Because PN is placed via IV, a contraindication is if a patient does not have a PICC or central venous IV line. Other contraindications include allergies to components of TPN solution and active infection.
The job of the RD is to calculate the TPN formula that will not only give the patient all of the correct macronutrients, but ensures the patient is getting enough vitamins and minerals while also keeping electrolyte levels balanced. If able, the patient may still eat orally while on TPN. Like enteral nutrition, most times the goal of TPN is to wean patients off of supplemental nutrition in order to reach adequate nutrition status with oral feedings only.
One of the most important quality checks a person can do before deciding on a long term care facility is ensuring that it has the staff that meets their individual needs (2). This many times includes a Registered Dietitian. Individualized nutrition care directed by a Registered Dietitian results in improved outcomes related to increased energy, protein and nutrient intakes, improved nutritional status, and improved quality of life.
RD Nutrition Consultants LLC, is the industry leader in Consultant Dietitian Services Nationwide. We specialize in providing contract Registered Dietitian services in a wide variety of healthcare and wellness organizations.
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