Malnutrition and the Dietitian:
Two Important Roles Often Overlooked in Health Care Facilities
- Stephanie Copeland, Registered Dietitian/Licensed Dietitian -
Malnutrition (the state produced by excess or deficient
energy (calorie) or nutrient intake or by an imbalance
of nutrients) of many types is common in nursing home residents,
with a prevalence ranging from 17% to 65% (1), while studies
of hospitalized patients have shown 30%-50% to have protein
calorie malnutrition (PCM) (2). In some cases, diseases
related to malnutrition are the major reason for admission.
Nutritional problems may also result in readmission to
the hospital either directly (for example, dehydration)
or indirectly (for example, infection).
Even with such a high rate documented, nutritional elements
are often overlooked by medical professionals and may be
a key element in a plaintiff’s claim or defense of
a client.
Risks and Complications of Poor Nutritional Status:
- Inadequate fluid intake, which is extremely common,
leads to dehydration and other complications.
- Severe malnutrition puts patients at higher risk
for death, sepsis, infections, and increased length of
hospital stay.
- Severe Protein Calorie Malnutrition (PCM) alters
tissue regeneration, inflammatory reaction, and immune
function.
- PCM has been associated with decubitus ulcers, cognitive
problems, orthostatic hypotension, infections, and anemia
(3).
- Low levels of vitamin C have been associated with
decubitus ulcers (4), while PCM and vitamin D deficiency
are important factors associated with hip fractures, a
frequent cause of morbidity and mortality in residents
(5).
- Zinc and selenium deficiency can aggravate immune
deficiency and delay wound healing (3).
- A 1991 study revealed that about half of the people
over age 65 who are hospitalized with illnesses accompanied
by dehydration die within one year of admission.
- Malnourished patients are more likely to have postoperative
complications than well-nourished patients.
- Diabetic complications have a direct correlation
to nutritional status and patient nutritional education.
- Most physicians and nursing staff have had inadequate training
in nutrition, and studies have shown that they fail to
treat patients with poor nutrition.The signs and symptoms
of nutritional deficiencies or toxicities can be similar
to those of other medical conditions, and nutrition related
diagnoses are often not made by physicians or suspected
by nursing staff. The cost-cutting environment of healthcare
which is most readily seen in reduced head counts is a
short-sighted approach when applied to nutrition intervention
and the role of the Dietitian.
Dehydration alone is probably one of the most common and
most cost-efficient nutrition related conditions to treat
or avoid if interventions and care plans are in place and
followed. If left untreated, it is one of the most common
and most costly problems identified in the elderly population,
especially those in long term care (LTC) settings. Because
of this, HCFA surveys now include detailed monitoring of
hydration standards and implementation procedures in LTC
facilities (6). The Hydration Management Program from Novartis
Nutrition reports that 12-25% of LTC residents are affected
by dehydration, and that over 50% of dehydrated residents
with other medical problems die. Clinical signs and symptoms
of dehydration include decreased blood pressure, increased
heart rate, decreased cardiac output, decreased weight,
electrolyte abnormalities, fever, confusion/change in mental
status, constipation, and poor skin turgor. Increases in
lab values (due to decreased blood volume) such as hemoglobin/hematocrit,
BUN/creatinine, and albumin may also mask other potential
deficiencies.
The Surgeon General has stated, "If you are among
the two out of three Americans who do not smoke or drink
excessively, your choice of diet can influence your long-term
health prospects more than any other action you might take." The
Surgeon General's Report on Nutrition and Health has also
stated that eight of the ten leading causes of death, including
coronary heart disease, stroke, some types of cancer, and
diabetes mellitus, are related to diet and alcohol.
Education requirements for physicians and nursing staff
usually consist of no more than a one semester course in
nutrition. Because of this, the registered dietitian (RD)
is a key member of the interdisciplinary team. Registered
dietitians are the experts in nutrition and dietetics.
A common misconception among the public and those in healthcare
is that dietitians do little more than plan menus or counsel
patients on weight loss or diabetes. Clinical RD's have
extensive knowledge in medical nutrition therapy specific
to almost any disease or condition, parenteral and enteral
nutrition formulas and requirements, supplemental drinks,
e.g., Ensure (there are multiple supplements with specific
indications for different conditions), nutritional treatment
of decubitus ulcers, and drug/nutrient interactions, to
name a few. The education required for a degree in nutrition
and dietetics is based primarily on science courses including
medical nutrition therapy, metabolism, biology, chemistry,
physiology and anatomy. The American Dietetics Association
defines a Registered Dietitian as one who has "completed
a baccalaureate degree in dietetics or a related area at
a regionally accredited US college or university, completed
a supervised clinical experience, and passed a national
examination administered by the Commission on Dietetic
Registration, which is recognized by the National Commission
for Certifying Agencies. To retain registered dietitian
status, continuing education activities are required. Registered
dietitians are qualified to perform nutrition screening,
assessment, and treatment."
Due in part to limited reimbursable services, dietitians
are often underutilized, and this can lead to a lack of
recognition of their importance as a member of health care
teams. In recent years, however, Medicare and JCAHO surveys
have greatly increased their focus on nutrition related
issues, and new health care reform is leading health care
providers and payers to implement new approaches that will
meet demands for cost containment and quality care. Dietitians
and medical nutrition therapy play key roles in identifying
those at risk and improving patient outcomes resulting
in improved quality of life and cost savings. Medical nutrition
therapy and proper documentation of dietetic services and
outcomes are also proving to be essential in protecting
against litigation.
References
1. Drinka, P.J, Goodwin, J.S. Prevalence and Consequences
of Vitamin Deficiency in the Nursing Home: a Critical Review”.
Journal of American Geriatric Society. 1991;39:1008-17.(Medline)
2. Morley, J..E., Silver, A.J. “Nutritional Issues
in Nursing Home Care”. Annals of Internal Medicine
1995; 123:850–9.
3. Konstantinides,F. “Nutritional Assessment of Hospitalized
Patients: A Long Overlooked Area of Lab Testing”.
Clinical Lab News. Feb 1998.
4. Morley, J.E. “Nutritional Status of the Elderly”.
American Journal of Medicine. 1986;81:679-95.
5. Goode, H.F., Burns, E., Walker, B.E., “Vitamin
C Depletion and Pressure Sores in Elderly Patients with
Femoral Neck Fracture”. British Medical Journal.
1992;305:925-7.(Medline)
6. Pierron, R.L., Perry. H.M., III, Grossberg, G, Morley,
J.E, Mahon, G, Stewart, T. “The Aging Hip”.
Journal of American Geriatric Society. 1990;38:1339-52.(Medline)
7. Instructor's Handbook to In-service Training, Hydration
Management Program. Copyright 1999 Novartis Nutrition Corporation.
Biography - Stephanie Copeland, R. D., L. D.
Ms. Copeland provides direct patient care for inpatient
and outpatient settings in hospitals, nursing homes,
physical rehabilitation facilities, Hospice, home health,
and private consultation. She provides education to patients/family
on specific therapeutic diets and food/drug interactions.
She serves as a member of the Wound Care Team; developed
protocol for nutrition therapy with respect to all stages
of wounds/decubitus ulcers.
She has implemented education
programs for diabetic, pulmonary and cardiac patients.
Ms. Copeland has also completed a legal assistant program.
She has extensive knowledge of medical nutrition therapy,
patient nutritional assessments with regard to dietary,
clinical, biochemical and anthropometric parameters.
She
has participation in several surveys with the JCAHO Quality
Assurance Team.
She has served as a consultant for nursing homes during
Medicare surveys.
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