Intern Name: Geanella Vera-Avellan

Note: List references you used to answer the questions at the end of this assignment. For this
assignment, it will help you to read the position papers first that are posted as required reading.

Read (see postings of papers on website as well)

· Position of the Academy of Nutrition and Dietetics: Food and Nutrition for Older Adults:
Promoting Health and Wellness
(online at www.eatright.org or J Acad Nutr Diet. 2012;112:1255-1277.)

· Freedom of Choice: Updated Dining Practice Standards Call for Diet Liberalization
https://www.caringfortheages.com/article/S1526-4114(15)00295-4/pdf

· Desirable Body Weight In Older Adults: An Analysis of the Evidence

· The Role of Nutrition for Pressure Injury Prevention and Healing: The 2019 International
Clinical Practice Guideline Recommendations

Part 1: Terminology, Medications, Lab Tests, Procedures, and Physiology

Review

In your own words, define the following. We do not look for textbook answers. Focus on what is
important to know as a Nutrition Professional, future RDN

a) Describe the difference between the models of a traditional LTC facility and a
Continuing Retirement Community (CCRC).

CCRCs provide different levels of care based on their residents’ needs by offering a wide
variety of services to provide seniors a sense of stability and support throughout the phases
of their aging process. LTC provides assistance to older adults who may need more help with
daily living situations. CCRCs and LTC differ in the levels of care they each provide. CCRCs
are best for seniors who are independent, but may need some help or assistance with daily
tasks such as cooking. On the other hand, LTC is more for seniors who may require 24-hour
support with all kinds of living situations, or to manage more chronic conditions.

b) What are the differences between the federal programs of Medicare and Medicaid in
the elderly?

The differences between Medicare and Medicaid when it comes to older adults is that
Medicare is a federal program that provides health coverage for adults who are 65+ years old,
or if they are under 65 years of age but have a disability. However, Medicaid is a state and
federal program that also provides health coverage and other living assistance programs for
those who have very low income, no matter their age.

c) What are some of the causes of poor appetite in the elderly resident?
Certain chronic conditions such as cancer, Parkinson’s disease, diabetes, and dementia can
contribute to changes in appetite. Also, the physiological changes of aging lead to reduced
resting energy expenditure, which often leads to reduced food intake. Other reasons that may
lead to loss of appetite in older adults are depression due to overwhelming feelings that can
impact on daily tasks such as getting out of bed, eating and walking.

d) The following medications are often used to enhance appetite in the elderly.

Describe some characteristics of these meds that are important for the RDN to know. For
example, think of their mechanism of action or why one appetite stimulant would be a better
option over another one.

Megace

This is an appetite stimulant medication that contains progesterone, which is used for
the treatment of severe weight loss such as seen in anorexia, cachexia, different
types of cancer, and wasting syndrome as seen in patients with AIDS. The exact
mechanism of action is still being explored, but, the way this drug is known to work is
by suppressing luteinizing hormone (LH) by inhibiting pituitary function which is where
LH is made.

Marinol

This is a synthetic form of THC, a psychoactive component of cannabis. Similarly, to

Megace, Marinol is used for treatment of anorexia, and for patients with cancer-
cachexia. THC has effects on the cannabinoid-1 and cannabinoid-2 receptors, which
results in effects such as increased appetite.

Remeron

This medication is also known under the name of mirtazapine, which is used for the
treatment of major depressive disorder (MDD). Remeron has been used for treatment
of lack of appetite in individuals with anorexia nervosa when it is administered in
conjunction with other psychoactive drugs. The exact mechanism of action of this
medication is not known completely, but its effects on the serotonin system causes a
fast onset of action which releases an increase of serotonin.

e) Alzheimer’s Disease
How does the disease develop and progress? What are some hypothetical causes? How
does Alzheimer’s differ from Dementia?

Alzheimer’s Disease is a specific and severe brain condition that accounts for 60-80% of
dementia cases. Dementia is a term often used when describing symptoms such as decline in
memory and other cognitive skills. The exact cause of Alzheimer’s disease is not fully
understood, but what is hypothesized to be a combination of age-related changes that
happen in the brain, along with other genetic and lifestyle factors.
Alzheimer’s has three stages by how the disease usually progresses: mild, moderate, and
severe.
Early stage of Alzheimer’s is also considered as “mild”. This is when a person may still be
independent of activities of daily living (ADLs). The person may have more periods of
forgetfulness of familiar words or location of everyday objects.
 Middle stage of Alzheimer’s is also considered as “moderate”. This is known to be the longest
stage of the disease progression. This may cause a person to feel frustrated and unable to
recall important information. During this stage, the person may need some assistance with
ADLs.
Late or final stage of Alzheimer’s is also considered as severe. This is when the person loses
their awareness of current experiences and their environment. Communication, memory and
cognitive skills worsen during this stage and patients need extensive daily care.

f) Parkinson’s Disease
Define the disease process, include the most used medication, Levodopa, and discuss the
interaction with dietary protein. What suggestions would you make to a family member of a
patient being treated with this medication?

Parkinson’s Disease is a brain disorder that affects movement and can develop slowly over
years. Symptoms can differ for everyone, but most of the signs/symptoms include tremor or
shaking of extremities such as hands or fingers. Slowed movement, rigid muscles, and
impaired posture/balance problems.
When it comes to medications, one of the most well-established and most effective drugs for
this disease is Levodopa. This medication has been documented to have side effects of
nausea and appetite loss. In addition, Levodopa competes with protein for absorption in the
small intestine. From a nutrition standpoint, for patients with Parkinson’s, it is best to have a
diet high in fiber from fruits, veggies and whole grains. The best solution to administering
Levodopa is to eat it at meal times with foods that are not high in protein, so it does not
interfere in the absorption of this medication. Snack pairings such as ginger tea and crackers
can help alleviate some of the nausea symptoms and this snack is generally low in protein,
therefore it will not interfere with absorption.

Part 2: Review of MNT

In your own words, define the following. We do not look for textbook answers. Focus on what is
important to know as a Nutrition Professional, future RDN

a) Define Resident Centered Care.

A Resident Centered Care (RCC) is a model of senior care that is centered around the
patient’s emotional needs and care preferences. Overall, this model places emphasis on the
relationships in the care of the patient, rather than the approaches that focus on the physical
health of the residents.

What are the challenges with RCC while following the requirements for a therapeutic diet?

Because quality of life is the standard with RCC, a therapeutic diet may not be followed if the
resident/patient does not like it. Since RCC allows the patient to define their own quality of
life, the best way to go about this is to incorporate the resident’s preferences and choices into
his plan of care and arrange a risk agreement with them.

b) What is a liberalized diet?

A liberalized diet allows residents to have autonomy for their dietary choices within reason
and this should be done under evaluation of an RD. Liberalized diets allow residents to have
RCC.
 How does it help to improve nutritional status in the LTC resident?

When used appropriately, a liberalized diet can enhance quality of life and nutritional status
as the patient is consuming more nutrients from a liberalized diet compared to a very strict,
therapeutic diet.

One main benefit from a liberalized diet is the decreased risk of malnutrition, as liberalized
diets are often more palatable for the residents, which encourages them to eat more, and as a
result, eating more nutrients and frequency of meals.

Part 3: Case Study

Fred (96yo) and Wilma (92yo) Flintstone lived for many years in assisted living, but recently moved
into a long-term care facility. Fred’s ADL include walking with a cane and has been spending most of
his time sitting in his chair and watching TV most days. He has not been taking his daily walks.

Fred has developed a sacral stage 3 pressure injury. His appetite was great as he enjoyed
brontosaurus ribs, but Wilma states that he complains that he can’t taste the food well and his intake
has decreased by 50%. She also noticed that he prefers soup and other soft foods for his meals.
Fred has been prescribed medications of Lipitor, Lasix and zolpidem.

a) Based on the readings, which of the formulas below would you use to calculate
Fred’s kcal needs?
a. 22-28 kcal/kg
b. Harris Benedict x1.0-1.5 IF
c. 30-35 kcal/kg
d. Mifflin St. Jeor x1.1-1.4 IF

b) Based on the readings, which of the formulas below would you use to calculate
Fred’s protein needs?
a. 0.8-1 g/kg
b. 1.25-1.5 g/kg
c. 1.4-1.75 g/kg
d. 2-2.5 g/kg

c) Based on the readings, which of the formulas below would you use to calculate
Fred’s fluid needs?
a. UOP + 1000 ml
b. 1 ml/kcal
c. Standard 2000 ml/day
d. 1.5 ml/kcal

Do you think he is currently meeting his caloric and protein needs?

Based on the information provided above, he is only meeting about 50% of his needs, and
eating more soups and soft foods, which naturally are lower in calorie and protein, unless the
LTC facility they currently live in are making sure he is getting enough protein and calories in
each meal, then he is most likely not meeting his needs.
Why would the wound not be improving despite if he is meeting his nutritional needs?

The cause of the wound not improving even if he were meeting his nutritional needs could be
due to the fact that he stopped taking his daily walks, and now spends most of his day sitting
on the couch and watching TV. Another reason could be him not meeting his fluid needs,
which aids in wound healing, which is not mentioned in the introduction paragraph, so there is
no way of really knowing.

d) What micronutrients would you consider for him and why? State how long and in
what amounts you would give these.

For this pressure injury stage, I would recommend vitamin C with a dose of 1000 mg/daily.
Vitamin C is a cofactor in the process of collagen formation, therefore, it is critical as part of
the healing process.

In addition to vitamin C, zinc and copper have been associated with collagen formation, and if
the patient has deficiencies in these micronutrients, then there will be a delayed healing of
these ulcers. Zinc should be supplemented only if a deficiency is present and more than 40
mg of elemental zinc daily since too much zinc can lead to poor wound healing and poor
absorption of copper since these two minerals compete with each other.

Lastly, research on the benefits of glutamine and arginine when it comes to pressure injuries
have been studied. Studies suggest that an arginine dose from 6 to 9g daily can help increase
the healing process of pressure ulcers. When it comes to glutamine, the dose recommended
is 0.57 g/kg/day when it comes to wound healing.

e) Working as part of an interdisciplinary team, what interventions are you looking for
from the other disciplines to improve Fred’s pressure injury.

As part of Fred’s plan of care when it comes to healing his pressure injury, we want to make
sure he is getting repositioned every 2 hours -- which is the standard for prevention of
pressure ulcers. We want to make sure to release some of that pressure, that there are
wedges or pillows to support Fred’s change in body position when he is in bed. We also want
to make sure a nurse is changing the wound dressing placed on the pressure ulcer every so
often to make sure the skin remains clean and dry. Lastly, we want to make sure we are
working with OT/PT to get back to his daily routine of taking walks and keep him moving.

f) What do you think would be causing Fred’s taste changes and what suggestions
would you make?

I believe what is causing Fred’s taste changes is a combination of factors. First, with aging,
taste buds lose their function of being able to detect flavors. Second, with Fred’s taste
changing and him only preferring softer foods, this could be due to poor dentures, and just
having that transition from regular foods to a different texture may need some time to adjust.
The medications Fred takes may also play a role in his change of appetite and loss of taste.
Statins have been shown to cause these side effects for individuals that consume these
meds. Lastly, because of his pressure injury and other factors, he has not been having as
much movement as he used to, even with his cane. An increase in exercise and overall
movement can help boost appetite.

What recommendations do you have to improve Fred’s appetite?

I would recommend Fred to create a routine that will make him feel good. This can include
those daily walks he used to incorporate in his routine as this will not only add to his daily
activities, but it will also help boost his appetite. I would also suggest for him to look for foods
 that are more nutrient dense. Since he is at a LTC facility, they most likely are preparing his
meals. I would recommend asking for softer foods that will not cause discomfort when eating.
I would also recommend him to stick to a scheduled eating routine. In addition, I would add
soft snacks in between meals such as cooked fruits, yogurt, pudding smoothies and shakes
which can help him get more kcals and protein to reach his nutrient goals. Lastly, I would
suggest an appetite stimulant if these tips do not work for him or are not easy for him to adjust
to.

Part 4: Ethical Issues in LTC Environments

The following are common situations that you may encounter while working with residents.
There is really no completely correct answer to these questions, but using your critical
thinking skills and nutrition knowledge, suggest solutions to these questions. Keep in
mind that quality of life is very important to the residents, and that long-term care facilities
are considered their homes. Residents’ rights are very important in LTC when it comes to
food and preferences.

Include the nutrition problem and interventions you would use in your nutrition care
plan. Also include a possible PES statement for each situation.

Think through the situations in the cases below prior to answering the question.
Every case study below has a dilemma. It helps to identify what that is first.

1. A 84-year old male resident is admitted to the long-term care facility for
extended stay due to need for nursing care for a stage III pressure injury on the
sacrum. When the RD reviews the resident’s labs, the following is noted:

Albumin- 3.0 mg/dL

Na WNL
BUN- 50 mg/dL
Creatinine- 2.1 mg/dL
Based on your knowledge, what would be your nutrition care plan?

PES: Increased nutrient needs (energy/protein) related to increased physiological

demand for healing as evidenced by stage III pressure injury to sacrum

At first, looking at his CMP labs, the BUN/Cr ratio indicates he may be dehydrated,
and with a stage III pressure injury, this is not ideal as with wounds, as there is an
increase in fluids to begin the healing process. I would also communicate with the
wound nurse to see if the pressure injury is healing if it is worsening, and to see what
interventions are being made on their end.
I would incorporate his needs as:
30-35 kcals/kg/day, 1.5-2.0 g/kg/day, and 1ml/kcal/day.
I would recommend nutrient dense meals focusing on high energy and high protein
like whole wheat tuna sandwich with cooked veggies and with a high protein
supplement such as Ensure to drink in between meals, and also suggest a
multivitamin that can provide him with those essential minerals that will boost
collagen formation and expedite the healing process of this wound.

2. A 73 year-old obese female resident with a BMI of 38 and a diagnosis of

diabetes enters your LTC community with a stage II pressure injury on her heel. Her
albumin level is 2.4 mg/dL. What interventions could be part of your nutrition care
plan? Hint: Think of her BMI, think of how much she may weigh, think of reasons
why she may have a wound, think of potential issues in the future with regard to
resident’s rights.

PES: Food and nutrition-related knowledge deficit related to poor diabetes

management as evidenced by stage II pressure injury to heel

I would first start my assessment by looking for the most recent HgA1c levels to have
a better understanding of the severity of diabetes. I would also recommend
Accuchecks every shift to get a better understanding of blood sugar management.
When it comes to calculating needs, I would recommend 1.2-1.5 g/kg/day of protein,
while adding a multivitamin with zinc and vitamin C that can help with healing, I would
visit the patient and see if she manages her diabetes with food or just medication at
home. I would recommend her to have small but frequent meals throughout the day
for better blood sugar control, and explain to her that having complex carbohydrates
such as whole wheat bread paired with a lean protein such as an egg and healthy fat
such as low-fat cheese can help manage blood sugars as well. Lastly, I would
recommend a minimum of 15-min daily walks when the pressure injury heals to
encourage healthy movement into her routine which can lead to safe weight loss.

3. A resident with mild dysphagia is admitted to your LTC community. After

being seen by the speech therapist, the resident is placed on a pureed diet with
nectar thick liquids. You observe the resident eating poorly at meals and “sneaking”
thin liquids from the hydration cart (a cart on the resident’s unit to get water, juice,
etc.). What course of action should you take? Does this behavior put the facility / the
resident at risk?

PES: Swallowing difficulty related to mild dysphagia as evidenced by pureed diet

and nectar thick liquids modifications made by speech therapist

I would visit the patient and have a conversation and ask them what is causing them
to go for foods and drinks that are not part of his diet. I would also ask for their
preferences, and even reach out to a family member to find out what they enjoy and
what they don’t like. If the lack of adherence to this diet texture and modification is
due to taste, I would explain the risks of continuing to do so and that with time, their
taste buds will adjust to these minor changes. I would also have an interdisciplinary
meeting with the rest of healthcare professionals that may be involved in his case,
and let them know what the patient is doing and how these behaviors are risking their
health. These behaviors can also put the facility at risk of choking or aspiration if the
patient continues to follow these actions I would have proper communication
 between the care team and the family of the patient to keep them updated and also
have a document in writing that the patient is not adhering to their diet modifications
and textures made by the speech therapist.

References

“What's the Difference Between CCRC & Assisted Living?” Forest Hill, 18 Jan. 2018,
foresthillretirement.org/whats-difference-ccrc-assisted-living/.

“Mirtazapine.” DrugBank Online, go.drugbank.com/drugs/DB00370.

“Stages of Alzheimer's.” Alzheimer's Disease and Dementia, www.alz.org/alzheimers-

dementia/stages.

Holden, Kathrynne. Parkinson’s Disease: Nutrition Matters. National Parkinson’s Foundation.

https://www.parkinson.org/sites/default/files/Nutrition_Matters.pdf

October 31, 2018. “Supporting Diet Liberalization in Health Care Communities.” Pioneer
Network, 1 Aug. 2020, www.pioneernetwork.net/supporting-diet-liberalization-in-health-care-
communities/.

“Importance of Liberalized Diet for Older Adults.” Dietitians On Demand,

dietitiansondemand.com/the-importance-of-the-liberalized-diet-for-older-adults/.

Saghaleini, Seied Hadi et al. “Pressure Ulcer and Nutrition.” Indian journal of critical care
medicine : peer-reviewed, official publication of Indian Society of Critical Care Medicine vol.
22,4 (2018): 283-289. doi:10.4103/ijccm.IJCCM_277_17