An intern’s perspective: Series written by Jessie Donaldson (Part 1 of 5)

4/20/2020

Topic 1: The Importance of Meal Rounds in Long-Term Care

          Long-term care RDNs rely heavily on observation to identify and address feeding issues in residents. As a student, I was surprised to find just how important meal rounds are. As I assisted my preceptor in meal rounds, I learned a lot about the feeding issues that older adults often face and the various tools an RDN may use to treat them.

          Among older adults living in nursing homes, it is estimated that 40-60% experience feeding difficulties.¹ This is not surprising, given that an estimated 47.8% of nursing home residents have Alzheimer’s or other dementias.² Dementia leads to many feeding difficulties, as it often leads to pocketing of food, increased energy expenditure due to pacing, food refusal, agitation, and forgetting to eat.³ What’s more, dementia and other conditions can cause dysphagia, which involves difficulties swallowing food and/or fluids. For residents with motor neuron diseases like Parkinson’s, the physical act of getting food from their plate to their mouth can be laborious. With a population susceptible to unintended weight loss and malnutrition, all of these feeding issues pose a very high risk. This is what makes meal rounds such a powerful tool for RDNs.

By observing residents as they eat, an RDN or intern may notice one of the following situations:

• A resident coughs, gags, or sneezes between bites
• A resident drools or loses food and beverages out of their mouth
• A resident appears to be confused or agitated, and isn’t eating as a result
• A resident has trouble holding utensils or getting food onto them, due to tremors or limited mobility
• A resident complains of nausea or a lack of appetite

When one of these situations occurs, the RDN may take action by:

• Requesting an assessment for dysphagia from a speech-language pathologist
• Informing nursing that the resident needs assistance from staff with verbal cueing or physical assistance
• Documenting decreased meal intakes and monitoring for weight changes over time
• Requesting an assessment from occupational therapists to identify whether adaptive feeding equipment may help
• Offering the resident alternative foods
  • Finger foods like cut sandwiches can be especially helpful for those with motor difficulties or confusion
  • Snacks like yogurt or cottage cheese and fruit can add much-needed calories and may be better tolerated than full hot meals
  • A daily menu of familiar items should always be available as an alternative to the daily selection
  • If the resident has a specific preference, the RDN will notify the foodservice manager so the item can be served daily or as per the resident’s wishes

When an RDN conducts meal rounds, their primary goal is to help every resident get adequate energy and nutrient intake. The golden rule is, “food first”. If, however, every option above is exhausted and a resident is unable to meet their nutritional needs (as evidenced by significant weight loss or other signs of malnutrition), the RDN has a few other tools to use. First, CNAs and diet aides can be instructed to always offer residents whole or chocolate milk with their meals. The additional calories and protein in milk can make up for deficits caused by feeding issues. If the resident refuses or it isn’t enough, drinks like Ensure or Boost may be warranted. After prescribing one of these nutritional supplements, the RDN will assess the resident’s intake of them at future meal rounds.

Students learn much in their classes about nutrition assessments and nutrition-focused physical exams. Another important tool for RDNs that doesn’t receive as much coverage, however, is meal rounds. During my time as a student-intern, I learned how critical of a practice it is to observe residents as they eat.

References:

1. Aslam, M. and Vaezi, M., 2013. Dysphagia in the Elderly. Gastroenterology & Hepatology, [online] 9(12), pp.784-795. Available at: <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3999993/&gt; [Accessed 10 April 2020].
2. Cdc.gov. 2016. Faststats – Alzheimer Disease. [online] Available at: <https://www.cdc.gov/nchs/fastats/alzheimers.htm&gt; [Accessed 10 April 2020].
3. Hilliard, MS, RD, LDN, CSG, CDP, L., 2013. Caring for Dementia Patients. Today’s Dietitian, [online] (Vol. 15 No. 8), p.64. Available at: <https://www.todaysdietitian.com/newarchives/080113p64.shtml&gt; [Accessed 10 April 2020].

 

Jessie is just completing her undergraduate work at the University of Alabama and will be interning with the University of Delaware this fall.