Position of the American Dietetic Association: Liberalized Diets for Older Adults in Long-Term Care

1. Position Statement 

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 a liberalized diet. 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.

2. Demographics and Trends in Long-Term Care 

The over-65-year-old population comprised about 13% of the US population in 2000, and is expected to double in number to 70 million, or 20% of the population, by 2030 (6). Those aged 85 and over are predicted to increase in population from about 1.6% of the population to about 2.5% by the year 2030. Minority elderly populations are also growing minorities are projected to be 25.4% of the older population by 2030 (up from 16.1% in 1999) (6). All of these changes in the older population will have dramatic effects on health care and nutrition care of the nation's older adults.

In 1997, 1.47 million persons, 4.3% of all Americans aged 65 years and older, lived in nursing homes (6). When broken down by age group, the percentage increased dramatically by age, ranging from 1.1% for persons aged 65 to 74 years, 4.5% for those aged 75 to 84 years, to 19% for persons aged 85 years and older (6). The mean age of nursing home residents increased from 79.2 in 1984 to 80.5 years in 1994. Those older residents in 1994 also had a higher incidence of cognitive impairment and ADL limitations (7). Of the American older adults who turned 65 in 1990, it is estimated that 43% will need at least one type of long-term care facility in their lifetime (8). If residency ratios remain current, according to a study done by Rivlin and Weiner, the number of nursing home residents may double or triple by the year 2030 (9).

Older adults accounted for 36% of all hospital stays and 49% of all hospital days of care in 1997. The average length of their hospital stay was 6.8 days, compared to 5.5 days for younger people. Older adults had more physician contacts than younger people (11.7 vs 4.9 contacts) (6). Older adults in long-term care facilities are more chronically ill and require more care than most community-dwelling older adults. Of the 1.5 million people who resided in nursing homes in 1999-2000, 42% suffered from dementia, and 33% had symptoms of depression (1). These residents may also suffer from anorexia and involuntary weight loss, conditions that occur frequently outside the long-term care facility before their admission (10). Diabetes, congestive heart failure, chronic obstructive pulmonary disease, dysphagia, depression, and hypertension are common medical diagnoses for older adults in an institutional setting.

The average length of stay in a nursing facility is 2.5 years, according to the National Center for Health Statistics 1999 National Nursing Home Survey (11). Because the length of stay is so long, the nursing facility is considered the resident's home. The current trend is toward improving quality of care and quality of life and increasing each resident's role in making informed care decisions. These factors are outlined in the federal regulations issued by the Center for Medicare/Medicaid Services (CMS) as a result of the 1987 Omnibus Budget Reconciliation Act (12) and in the Joint Commission on Accreditation of Healthcare Organizations’ (JCAHO) Comprehensive Accreditation Manual for Long Term Care (13).

Current federal nursing home regulations protect a resident's right to refuse services or treatments and to choose alternatives. The law defines resident rights as the right to be free of interference, coercion, discrimination and reprisal from the facility in exercising his or her rights. According to the Code of Federal Regulations, “The resident has the right to be fully informed in language that he/she can understand of his/her total health status (includes functional status, medical care, nursing care, nutritional status, rehabilitation, and restorative potential, etc), including but not limited to medical condition” (12). The JCAHO standards also support a resident's right to informed consent. Informed consent is defined as “Agreement or permission accompanied by full notice about what is being consented to. A patient or resident must be apprised of the nature, risks, and alternatives of a medical procedure or treatment before the physician or other health care professional begins any such course. After receiving this information, the patient or resident then either consents to or refuses such a procedure or treatment” (13). To clarify, a resident has the right to refuse treatment; however, it is the responsibility of the facility health care team to explain to the resident, family, and/ or guardian the risks and benefits of refusing treatment.

The risks and benefits of MNT in declining health should be documented in the medical record. The dietetics professional's role includes assessing nutritional status, determining appropriate interventions and interviewing the resident for personal needs and desires. If the nutritional assessment reveals that the diet order is inappropriate for the individual resident, the dietetics professional should consult with the resident and make a recommendation to the physician for a more appropriate diet. If the diet order is still unacceptable to the resident, the dietetics professional should educate the resident (or legal guardian) about the risks and benefits of refusing the therapeutic diet. If, after receiving counseling and education, the resident refuses MNT intervention, a waiver or consent form that outlines risks and benefits and refusal of treatment should be signed by the resident (or the legal guardian) and placed in the medical record. This waiver should indicate that the resident understands the consequences of the choice. Once the resident's decision is made, the facility must support the resident's decision regarding choice and must serve as an advocate for the resident at all times. As long as the resident is deemed competent, his or her decision stands.

It was found that most residents in a nursing home with evidence of malnutrition were on restricted diets that might discourage nutrient intake

The dietetics professional must take a lead role in the assessment and counseling in these cases and must continually reassess, reeducate, and discuss new information with the resident (or legal guardian) as the resident's condition changes, so that informed decisions can continue to be made.

3. Institutionalized Older Adults and the Risk of Malnutrition 

Older adults in long-term care settings are often among the frail elderly. They are more likely to experience a number of problems—physical and social, acute and chronic—that exacerbate poor health and compromise quality of life. Nutrition care is well recognized as an important factor in improving longevity and quality of life, but the nutrient requirements of this population are not yet well understood (14). Good nutritional status in older adults benefits both the individual and society: health is improved, dependence is decreased, time required to recuperate from illness is reduced and use of health care resources is contained (4), (15). Conversely, undernutrition adversely affects the quality and length of life and, therefore, has aroused the concern of geriatric health professionals (16). The prevalence of protein energy undernutrition for residents in nursing home facilities ranges from 17% to 65%, making malnutrition one of the most serious problems facing health professionals working in long-term care (17). Malnutrition in the elderly is associated with poor outcomes and is an indicator of risk for increased mortality (18). Although Buckler (19) did not demonstrate a causal relationship between a restricted diet and malnutrition, it was found that most residents in a nursing home with evidence of malnutrition were on restricted diets that might discourage nutrient intake. Dietetics professionals working with older adults in nursing home settings must overcome many hurdles in order to help them obtain appropriate nutritional status. Barriers to adequate nutrition in older adults can generally be divided into two broad categories: physical problems and psychosocial concerns.

Common physical problems that affect nutritional status include poor appetite, weight loss, pressure ulcers, chronic disease, eating dependency, sensory loss and poor oral health. In addition, older adults are often taking several different medications at once, a situation that may affect their nutrient intake and utilization of nutrients consumed. Any of these problems can lead to or exacerbate existing malnutrition.

Loss of appetite is a major cause of undernutrition in long-term care. Unrecognized anorexia can lead to debilitation, primarily from weight loss (20). As appetite diminishes, intake of total energy, protein, vitamins and minerals is reduced, depleting the body of necessary nutrients. This predisposes older adults to an increased risk of illness and infection. At the same time, infections may lead to a higher metabolic rate, increasing the person's total energy and protein needs. A vicious circle ensues. Stringent diet restrictions that limit familiar foods and eliminate or modify seasonings in foods may contribute to poor appetite, decreased food intake and increased risk of illness, infection, and weight loss.

Weight loss in institutionalized older adults may be the result of a number of circumstances, both physical and emotional. Unintentional weight loss has been correlated with increased mortality, compromised ability to resist infections, and increased incidence of pressure ulcers (21). Protein-energy malnutrition (PEM) is common in connection with chronic disease and is associated with increased morbidity and mortality. Because the risk of PEM is related to the degree of illness, causal connections between malnutrition and a poorer prognosis are complex (18). In a review of changes in lean body mass, Demling also noted that changes in body composition are more reliable indicators of morbidity than are changes in body weight with a decrease in lean body mass of 40% associated with 100% mortality (22). When trying to minimize weight loss, limiting particular foods that are appealing may be counterproductive, while increasing exercise may increase food intake in older persons (23).

Older adults experience a higher incidence of risk and development of pressure ulcers. One study found that 11.6% of adults over 70 years of age experienced pressure ulcers, compared to only 6% of younger persons (24). Pressure ulcers are costly, with an estimated median cost of caring for a pressure sore at $25,000-$30,000 (24). Among older adults in nursing homes, pressure ulcers are associated with a four-fold increased risk of death, and a six-fold increase if the wound does not heal (24). Although pressure ulcers have multiple causes, nutritional status is a contributing factor. Residents who refuse to eat foods that are unpalatable and unappealing because the diet order is too restrictive and the food is bland are at risk of poor food intake. A poor intake can contribute to poor nutritional status, thus increasing risk of pressure ulcer development and/or poor wound healing.

Older adults also suffer from a higher incidence of chronic disease, most notably cerebral vascular accident, arthritis, Parkinson's disease, diabetes, and dementia. Some diseases, such as chronic obstructive pulmonary disorder and congestive heart failure, may result in increased metabolic demands and diminished appetite. Dementia syndromes, such as Alzheimer's disease may impair self-feeding, alter appetite, and increase energy needs. Nutrition restrictions may make food less appetizing, resulting in diminished intake and weight loss.

Long-term care residents ingest an average of eight medications per day. Of the more frequently used medications, 23 are known to cause reduced food intake and have side effects such as anorexia, nausea, vomiting, food aversions, somnolence, and disinterest in food (25). Accommodating food preferences maybe essential to counteracting the effects of polypharmacy in long-term care residents.

Incidence of eating disability in nursing homes is high. Data collected by the CMS in 1999-2000 indicates that 28% of nursing facility residents require assistance with eating, and 19.2% are totally dependent on eating assistance (1). A decline in functional ability can be a factor in accessing adequate nutrition. The problem is enhanced by staff shortages and the length of time required to feed a totally dependent resident. In addition, many residents require coaxing and encouragement to eat, increasing the staff time requirement.

The ADA recognizes that CMS staff members have given extensive consideration to finding ways of modifying regulatory policy to ameliorate the difficulties that facilities encounter in ensuring that residents receive adequate nutritional and fluid intake. A federal report released in July 2000 addressed the fact that understaffing contributed to “increased incidences of severe bed sores, malnutrition and abnormal weight loss among nursing home patients” (26). A study done by Kayser-Jones indicates that a minimum of 20-30minutes is needed to adequately feed a dependent resident and to promote a quality experience for the resident (27). Without adequate staffing, residents who need assistance will be at major risk of unintentional weight loss, malnutrition, and the resultant complications. It is imperative that dietetics professionals support legislation to improve nursing staffing ratios in nursing homes.

Sensory loss is common in the aging process. Visual impairment can diminish the appreciation of the color of foods and the ability to recognize them. Similarly, the role of aroma in stimulating appetite is diminished with the loss of olfactory ability. The flavor of foods may be altered for older adults because of loss of both olfactory and taste perception (28), (29), (30).

Older adults are more likely to develop dry mouth and other oral-health problems. People reporting dry mouth were less likely to eat adequate amounts of protein, folate, phosphorus, and copper. They also had lower intakes of calories, fiber, vitamin D, calcium, and other nutrients. A study of 449 people aged 70 or older found that those reporting dry mouth had fewer teeth than those who did not report the condition (31). Lack of teeth or poor oral health reduces chewing ability and limits food selection. Poor dentition or use of dentures affects the ability to perceive food flavor (29). Dysphagia also contributes to the decline in oral intake and enjoyment of eating. It is estimated that 53% to 74% of older adults in long-term care facilities may experience dysphagia symptoms during the eating process (32). According to CMS Online Survey Certification and Reporting (system) statistics, 35.3% of nursing home residents were on mechanically altered diets in 1999-2000, up from only 13% in 1992 (1). It is essential to maintain the highest level of dysphagia diet a resident can tolerate, and to prepare and serve altered-consistency foods in an attractive and appetizing manner. Nutrition restrictions, coupled with sensory losses, may result in limited food enjoyment and compromised food intake, potentially leading to unintentional weight loss and malnutrition (33).

Unfortunately, dietary departments are also experiencing staffing shortages. This makes it difficult to prepare numerous therapeutic diets. Staff time is better spent focusing on ensuring that food is palatable and attractive, and that individual needs are met.

An estimated 35% to 85% of nursing home residents suffer from malnutrition or dehydration (34), (35), (36), (37). Research has shown that older people are much less likely than younger people to “make up” for poor food or fluid intake at one meal by eating more at subsequent meals (38), (39), (40), (41). There is an additive effect each time a resident does not get enough assistance with eating, such that inadequate intake at even a few meals per week will inevitably result in unintended weight loss and malnutrition. Thus, the only way to reduce the rate of malnutrition and dehydration is to make sure that food and fluid consumption are optimized during each meal, snack, and hydration opportunity.

Many nursing home residents are physically dependent on others for assistance with eating and drinking (34), (35), (36). It is incumbent upon dietetics professionals to make sure that older people, who are willing and able to eat with assistance and encouragement, do not suffer from malnutrition and dehydration—and most certainly, not while residing in health care facilities. A critical shortage of nurse aides, or disagreements about appropriate minimum nurse staffing levels, should not prevent frail older people living in nursing homes from receiving assistance with eating.

The link between psychiatric well-being, food intake, and nutritional status is evident in persons of all ages, particularly in older adults (17). Depression among institutionalized older adults is common and can be caused by several factors, including loss of loved ones, loss of independence, loneliness, and failing health. These factors can contribute to a resident's lack of attention to their nutrition needs and food preferences, which results in a decrease in food intake and often malnutrition.

In 1998, as a result of recognizing many of the problems noted above, CMS implemented new survey initiatives which focused on four key areas: unintentional weight loss, pressure sores, dehydration, and dining and food service. These survey initiatives give guidance to surveyors on how to assess whether a facility is non compliant in any key area. The initiatives are also a wealth of information for the dietetics professional, and can assist in determining where changes need to be made. Each of these investigative protocols addresses food and nutrition concerns. The pressure sore protocol addresses the need for risk assessment, including the risk of compromised nutritional status such as unintended weight loss or malnutrition and the need to assess nutritional interventions that have been implemented as part of the care plan. The protocol for hydration addresses the need to assess the risk factors for dehydration, including whether the resident is dependent on staff for provision of fluid intake and whether the staff is providing sufficient fluids and providing fluids the resident prefers. The unintentional weight loss protocol addresses the need to assess risk factors such as malnutrition, dehydration, dysphagia, poor-fitting dentures, taste, and sensory changes, dependence on staff for feeding, and many others. This protocol also guides surveyors in assessing whether care plan interventions “such as…alternative eating schedule, liberalized diet…assistance and/or increased time to eat” have been developed to provide an aggressive program of consistent intervention by all appropriate staff (42).

4. The Role of Medical Nutrition Therapy in Long-Term Care 

Given the numerous problems faced by dietetics professionals who work with older adults in long-term care, it is necessary to evaluate the role of therapeutic diets in this population. The following questions need attention: Are restricted diets necessary? Do the diets offer health benefits to justify their use? Which residents will benefit from a therapeutic diet? These questions must be answered on an individual basis. Dietary modifications may have an impact on the flavor, variety, or texture of food, which can affect its appeal to nursing home residents. In addition, many states require that dietetics professionals meet only minimum standards of work time, thereby not allowing sufficient time to individualize feeding programs or diets. Overly restrictive diets are frequently too low in calories, bland in taste, and unappealing to the eye. Simplified diets have several benefits as depicted in the below (43).

5. Diabetes 

Research has shown that carbohydrates from sugars are no more rapidly absorbed than carbohydrates from starch when included as part of a meal plan (44). The goals of nutrition intervention should include the improvement of overall health through optimal nutrition. Experience has shown that older adults in long-term care eat better when they are given a less restrictive diet of “regular” foods rather than an energy-controlled diet. The current American Diabetes Association position statement states: “The imposition of dietary restrictions on elderly residents with diabetes in long-term health facilities is not warranted.” The position paper also states there is no evidence to support “no concentrated sweets” or “no sugar added” diets. It is preferable to make medication changes rather than implement food restrictions in order to control the blood glucose (44).

The benefits of “regular” diets include consistent mealtimes and portion sizes, which are important to diabetes management, and the potential to improve quality of life as well as intake. A key element in the use of regular menus in long-term care facilities is consistency in carbohydrate intake at meals and snacks. Such an approach incorporates sucrose-containing foods as part of the carbohydrate intake. This is in keeping with current nutrition recommendations regarding sucrose intake (44).

Older adults with diabetes on any type of meal plan should have their blood glucose levels monitored to evaluate the effectiveness of the nutrition intervention on glucose control. Those who do not tolerate a less restrictive approach need to be reevaluated by the dietetics professional; recommendations for adjustment of diabetes medication or individualization to a more controlled diet can be made using the results of capillary blood glucose monitoring.

6. Cardiac Disease 

Anorexia associated with cardiac disease may also lead to weight loss. Medications that regulate cardiac disease often suppress the resident's appetite for food (20). Available epidemiological evidence indicates that as age increases above 44 years, the importance of elevated serum cholesterol levels as a risk factor for coronary heart disease decreases and virtually disappears after the age of 65 years (45), (46), (47). Therefore, the appropriateness of low-cholesterol diet prescriptions for older adults in long-term care facilities is questionable (48), (49), (50). While practitioners working with older adults should certainly be cognizant of cardiac problems, malnutrition is a more serious threat to the majority of older adults than is elevated cholesterol (51). Menu planners should not attempt to improve a client's lipid profile by implementing radical shifts in eating habits. The goals of dietary modification are to maintain current weight and blood cholesterol levels, to encourage consistent dietary intake, and to preserve eating pleasure and quality of life. Menu modification may include the following— using reduced-fat (2%) milk or, if tolerated, low-fat (1%) or nonfat (skim) milk; substituting polyunsaturated oils and mar garines for saturated fats; and substituting lean cuts of meat for fatty meats (35). Older adults should make every effort to eat a healthy diet and follow the Food Guide Pyramid.

Maintaining a diet pattern that emphasizes fruits, vegetables, low-fat dairy, and lean meats and is reduced in fat can still be appetizing. The use of dietetics professionals and other members of the health care team with culinary expertise to enhance the taste and flavor of food may in fact improve overall intake while still providing a heart healthy diet (35).

7. Hypertension 

Low-sodium diets are often poorly tolerated in older adults and may lead to loss of appetite, hyponatremia, or confusion (52). A decrease in food intake in reaction to a low-sodium diet has the potential to worsen a person's nutritional status and facilitate the onset of cardiac cachexia, respiratory infections, or pressure ulcers. Diets low in sodium may be perceived as bland and tasteless, diminishing the pleasurable experience of eating and promoting unnecessary weight loss. The possibility that the benefit of antihypertension treatment does not extend to individuals beyond a certain age threshold has been supported by several researchers (53). Congestive heart failure in older adults could be controlled with the use of drug therapy and a mild sodium restriction of 4 to 6 g/day (no added salt) instead of the 2g sodium diet prescription (52), (54), (55), (56).

In addition, the Dietary Approaches to Stop Hypertension (DASH) should also be considered. Research suggests the use of this diet substantially reduced blood pressure in both nonhypertensive and hypertensive individuals. The diet is rich in potassium, magnesium, and calcium with few other restrictions (57). Menu modification may include the following: use fresh or frozen rather than processed and prepared foods; use less salt in cooking and do not place a salt shaker on the table but allow flavoring with spice blend/enhanced flavor options instead of salt (35). Evidence is now emerging that suggests that compensating for taste and smell losses with flavor-enhanced food can improve palatability and/or intake, increase salivary flow and immunity, reduce chemosensory complaints in both healthy and sick elderly, and lessen the need for table salt (55), (58).

8. Renal Disease 

Older adults with renal failure in conjunction with other chronic medical conditions often have a high incidence of malnutrition (59). In long-term care the resident with renal disease requires special consideration (60). It is well documented that up to 50% of hemodialysis (HD) clients are malnourished (59). There is also an estimated protein loss of 8 to 12g with each dialysis treatment, increasing the protein requirement for individuals already at risk (61). Interventions to correct protein/ calorie malnutrition and a poor appetite may include liberalization of the diet. However, laboratory values, food intake records, and weight loss or gain should be closely monitored.

9. Risks vs Benefits 

Dietetics professionals must help residents and health care team members assess the risks versus benefits of therapeutic diets. Changes in diet and exercise patterns are most effective in the prevention of nutrition-related conditions when they are instituted early in life, but positive effects can occur at any age (62). Optimal nutritional status ultimately depends on adequate intake of food. A diet cannot be effective if it is not eaten. If a resident is non compliant and does not support the prescribed medical nutrition therapy, the diet may be ineffective and frustrating for both the resident and the health care team. In addition, if a resident's appetite is extremely poor or if substantial weight loss is a problem, treatment of malnutrition may override concern for an elevated serum cholesterol level or a history of hypertension. Also, restricting food in an effort to control blood glucose is not appropriate because of the risk of malnutrition; instead, the resident's medication should be reviewed.

Food has emotional as well as physical importance. The relationship of food to culture, ethnicity, religion, or personal meaning is a special consideration in any nutrition intervention. The pleasurable experience of food and eating can contribute notably to a person's quality of life and nutritional status (63). Dietetics professionals must help residents and health care team members prioritize any nutrition problems and recommend the nutrition intervention that balances both medical and quality-of-life needs. Thus, it may not be advantageous to initiate a restrictive nutrition prescription for a resident who suffers from poor appetite and substantial, unintentional weight loss.

10. The Role of Dietetics Professionals in the Management of MNT for Long-Term Care Residents 

Dietetics professionals’ primary role in the management of MNT for long-term care residents is to develop a nutrition care plan consistent with each resident's nutritional status, overall medical condition, and personal preferences and needs. Dietetics professionals can implement MNT in the following steps:

11. Summary 

Malnutrition, weight loss, and resident satisfaction are serious issues that need to be addressed by dietetics professionals working in long-term care facilities. MNT for older adults in long-term care is multifaceted and critical to reducing the risks of malnutrition and weight loss. To meet the needs of every resident, dietetics professionals must consider each person holistically, including personal goals, overall prognoses, benefits and risks of treatment and, perhaps most important, quality of life. For some long-term care residents the use of liberalized diets, when appropriate, can enhance both quality of life and nutritional status, thus increasing the resident's satisfaction with the meals provided and reducing the risks of malnutrition and weight loss.

ADA position adopted by the House of Delegates on October 26,1997, and reaffirmed on June 22,2000. This position will be in effect until December 31, 2005. ADA authorizes republica-tion of the position statement/support paper, in its entirety, provided full and proper credit is given. Requests to use portions of the position must be directed to ADA Headquarters at 800/877-1600, ext 4896 or ppapers@eatright.org.

Recognition is given to the following for their contributions:

Authors:

Becky Dorner, RD (Becky Dorner & Associates, Akron, OH); Kathleen C. Niedert, MBA, RD, FADA (The Western Home Communities, Cedar Falls, IA); Patricia K. Welch, PhD, RD (Southern Illinois University, Carbondale, IL)

Reviewers:

The Assisted Living Federation (Antoinette McMonagle, RD, US Foodservice, Columbia, MD);

Consultant Dietitians in Health Care Facilities dietetic practice group: Cheryl Carson, MS, RD (C.L. Gerwick and Associates, Inc., Overland Park, MO); Susan McCorkell Worth, RD (Creative Food Options, Beaverton, OR);

Dietetic Technicians in Practice dietetic practice group: Deborah L. Redditt, DTR (Clinical Nutrition Management Consultant, Palm City, FL); Georgia Wenzel, DTR (King's Grant, Martinsville, VA);

Linda S. Eck, MBA, RD, FADA (Genesis Health Ventures, Orwigsburg, PA);

Elizabeth K. Friedrich, MPH, RD (Consulting Dietitian in Long-Term Care, Salisbury, NC);

Gerontological Nutritionists dietetic practice group: Cheryl L. Meskus, RD (Webster Commons, Webster, MA); Lee Wolf, RD (Gordon Food Service, Springfield, OH); Betty Leif, RD (Sunrise Care Center, Inc, Milwaukee, WI);

Oncology Nutrition dietetic practice group: Barbara J. Dickson, MS, RD (Veterans Affairs Puget Sound Health Care System, Seattle, WA)

Members of the Association Positions Committee Workgroup: Sylvia Escott-Stump, MA, RD (Chair); Evelyn B. Enrione, PhD, RD; Kathleen C. Niedert, MBA, RD, FADA (Content Advisor)