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Malnutrition in a nursing home resident: defensible?

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Malnutrition in a nursing home resident: defensible?

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malnutrition in nursing home residentsUnder nutrition reduces the ability to heal pressure sores, increase muscle wasting, and reduce general strength as well as limit ability to rebound from acute illness. This increases mortality. Muscle wasting and reduction in general strength increase risk of falls and falls-associated injury.

But is under nutrition the nursing home’s fault?

Consider these medical reasons for malnutrition.
1. Lean body mass as well as body fluid content and bone mineral density are diminished in normal aging. Fat increases and replaces muscle tissue. Physiological changes of normal aging occur such as reduced gastrointestinal motility, decline in insulin sensitivity, and a decrease in dentition, thirst, taste, smell, and sight. All contribute to the risk for involuntary weight loss.

2. Neurologic diseases such as Parkinson’s disease and cerebrovascular disease can reduce swallow efficiency making it more difficult for residents to consume food and fluid. Swallowing disorders can lead to conditioned aversion to eating causing a progressive loss of weight including a more rapid loss of lean body mass than the usual aging process.

3. Other medical conditions such as severe COPD not only reduce swallow efficiency by decreasing the time for food to move down the throat but also increases air hunger and the need to breathe rapidly. Severe cardiac conditions may induce a severe weight loss. Loss of blood supply to the intestines may produce pain and early satiety.

4. Diminished cognition may alter the eating process. The nursing home staff may provide speech therapy intervention, altered eating strategies, and modified diets as well as coordinated staff approaches. In spite of this plan of care, the complexities of swallow inefficiency may progress unabated in certain individuals. Episodes of bronchospasm and aspiration pneumonia further weaken the elderly individual making swallowing less efficient and causing a reduction in appetite.

5. Medications may have deleterious effects on appetite and increase risk for involuntary weight loss. High doses of anti-psychotics may increase the risk of involuntary weight loss. However, in the absence of appropriate anti-psychotic medication, anorexia may occur if such medication was indicated. Medications used to treat depression may have a wasting effect upon weight maintenance but may be necessary to treat severe depression. Anti-cholinergic medications may increase confusion and dry mouth, increasing the risk for involuntary weight loss.

6. The effects of metastatic cancer can include weight loss. Some residents and their families do not want the resident to undergo testing to determine if cancer is present. Undiagnosed cancer that causes weight loss provides a medical defense for claims of malnutrition due to negligence. The medical record should be evaluated for symptoms consistent with a possible cancer diagnosis. For example, breast masses, gastrointestinal bleeding, or vaginal bleeding in a post menopausal woman can be signs of cancer.

7. Oral health may have a major effect upon appetite and ingestion. Oral hygiene may be difficult to maintain in agitated patients with dementia. Dental caries may also be hard to treat in such populations.

8. Conditions that decrease saliva production can markedly reduce enthusiasm for food as well as ability to ingest adequate quantities.

Weight loss exerts major effects upon the overall health of the frail elderly. Frail elderly who lose more than 4% of their weight have a higher mortality rate than non weight losers.

The medical, nutritional and nursing standard of care involves recognizing and treating the factors that can be changed which contribute to malnutrition.

Modified from Defending Long-Term Care Facilities: Unraveling Clinical Outcomes from the Natural History of Aging  and Nursing Home Litigation: Investigation and Case Preparation. Second Edition.

Med League provides expert witnesses with expertise in evaluating nursing home cases. Call us for assistance.

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