According to nutritional specialist and Registered Dietician, Janet McKee, falls and nutrition are intrinsically linked. Where dietary intake is poor, the risk of falls and other medical complications increases. This is especially true in the high-acuity elderly population we see now in long-term care. This article identifies the ways that malnutrition, dehydration, weight loss and poor nutritional intake can affect fall risk as well as covering how to implement prevention strategies to help avoid preventable falls.
Protein-calorie malnutrition is a common diagnosis in LTC communities which often results in the loss of muscle mass, muscle function and weight.
According to Janet McKee, "over 50% of skilled nursing home residents, and up to 87% of acute care patients experience protein-calorie malnutrition, weight loss and muscle wasting."
Since a lot of our new admissions are coming from acute care that's something we need to know to look out for. "If people come in malnourished, we need to treat that."
Malnutrition doesn't just affect residents physically, though. It can have a far-reaching impact on a resident's overall well-being. Janet McKee says, "poor food intakes affect everything. They [the residents] can have a low energy level. It affects their physical weakness and we don't think about this but what about their cognition?"
It's important we consider weight loss as a potential risk for falls and a possible catalyst for other medical complications upon admission. According to Janet, "Weight loss causes muscle mass catabolism, muscle wasting and weakness. [...] Muscles that are weak cannot sustain balance and that causes falls. So we want to keep these muscles as strong as possible."
Failing to prevent continuing weight loss can result in a fall which could result in a hip fracture. Statistically, this then presents further risks, all of which can severely impact a resident's quality of life, and potentially derail recovery.
When a resident is admitted who has experienced weight loss, or one of our residents begins to exhibit unplanned weight loss, Janet claims our mission as healthcare professionals is simple."Our goal is to get weight and muscle on them through nutrition and physical therapy."
Dehydration doesn't get nearly as much coverage as it should on the effect it can have on balance, awareness, and bodily health. In Janet's experience, "fluid deficits cause dehydration and imbalance of sodium, potassium, and electrolytes, which affects cognition, joint lubrication, [...] it affects balance and the ability to walk. [...] If your potassium is off, it causes confusion. Your brain waves do not coordinate with your muscles clearly and therefore you're a fall risk."
Additionally, she states that the "electrolytes in your blood control your neurological pathways. "Therefore, "if [residents] come in with dehydration [...] they're at risk of falls."
Now we know which nutritional concerns can pose a fall risk, let's find out how to go about identifying them and mitigating those risks.
Janet Mckee stresses the importance of working to "identify malnutrition and dehydration on the first day of admission to reduce risk [...] with an adequate nursing screen and a nutrition screen."
She highly recommends using a validated nursing assessment and nutrition screen to identify malnutrition and dehydration upon admission.
Examples of a validated nutrition screen are:
Janet states, "These are really important tools to accompany those nursing screens", but what are the next steps once you know you have a resident who is at risk of malnutrition based on these screens? The next step is to implement an interim plan of care for that resident.
Janet advises that "residents at risk for malnutrition should have an automatic interim plan of care to prevent malnutrition, dehydration and risk of falls within 24-48 hours of admission. This is so important."
One of the reasons that implementing an interim plan of care urgently is so vital is to prevent the problems from exacerbating before the Dietician can properly assess them but also to protect your facility from potential litigation.
Janet stresses that should a surveyor come into your facility and say "'this person fell. You knew that they had a history of falls, they had a neurological disease such as Parkinson's, and they had lost 24 lbs before admission, but yet you don't have that interim plan of care", then you're potentially going to be penalized. "We need to make sure that we're getting within 24 to 48 hours an interim plan of care to avoid these patients having further declines and increasing their risk of falls."
Failure to implement this interim plan of care is a huge problem, according to Janet. It becomes a problem "for the resident, for the facility, for survey risk and you're now at risk of litigation."
It's clear that putting together a plan of care immediately to address risks is of paramount importance but who is responsiblefor doing this and for seeing that it is properly implemented?
Nursing and nutrition services both have a significant role to play in fall prevention and identifying fall risk and they need to be a united force in mitigating those risks.
"This is truly a team effort. Nursing has its role and Nutrition has its role, but together [...] if we collaborate those services, we can build an interim plan of care in the first 24 hours that can substantially reduce fall risk."
So, who is responsible for doing the initial assessment, identifying a malnutrition or dehydration risk, and implementing an interim plan of care? Is it Nutrition or is it Nursing?
Janet suggests that it's Nursing's job to refer those at dehydration and malnutrition risk to the RDNI, which means that nursing needs to perform the initial assessment to identify risk and work with Nutrition to execute an interim plan of care as soon as possible. If there is no full-time dietician, or they can't consult with them right away for any reason then nursing needs to put together and action the interim plan of care until the dietician can advise. It is then the job of the Dietician/Nutritionist to complete a comprehensive nutrition assessment for that resident and address the risk of protein-calorie malnutrition.
To speed this process along and negate human error, Janet recommends setting up an automation from your EMR which refers to the RDN on all assessments that identify a risk.
After this assessment by Nutrition, both parties can outline the individualized plan of care and execute it together collaboratively. After all, we want the same thing here, to see the resident well and happy so we should be willing, or rather intentional regarding interdisciplinary teamwork.
"Identifying and treating protein-calorie deficits and preventing weight loss are major steps in a fall prevention program."
Janet gives us some of her top tips for getting a new admission who is identified as a fall risk due to weight loss or poor intake of nutrition and fluids off to the best start before an individualized plan of care can be defined.
Janet McKee says: "On admission if you have someone that is a fall risk because they've lost weight and they also have a poor intake, even if they have CHF if they're only eating 25% of their diet, is it really necessary to put them on a 2-gram sodium diet? I don't think so."
There is very little, to no clinical research that shows the majority of patients in long-term care or acute care (unless they have severe CHF and they're younger) benefit from strict diet."
"This can all be done on admission. So if you have someone that is very weak, has lost a lot of weight, they have a stage one pressure ulcer, we can easily fortify their foods."
Especially when repeated refusals of nutrition interventions are a problem and refusals are putting the resident at risk of a negative outcome, it is important to involve their family in the situation and seek insight from them.
Regarding family involvement, Janet states "It's important because they might know something we don't know. For example, maybe the person is not able to communicate because they had a stroke, and they like buttermilk and corn bread, but we won't know that until we communicate with the family. It's very, very important to do that."
Janet advises that "one size does not fit all. We need to make sure that we customize our care as much as possible and individualize it. That's why we're all in healthcare: to provide a customized, individualized service. We need to ask them what they like to drink. Ask them "Would you like to have grits or oatmeal, or would you like to have toast? All can't be treated the same way, like a textbook."
"We need to get people hydrated, it's great to have hydration in the lobby. The families love it! Use dispensers for water and flavored beverages and ensure thickened beverages are available and offered to residents between meals."
One key thing Janet McKee suggests that healthcare professionals and dining personnel can do to improve nutritional intake and outcomes for residents is to always remember that people "eat with their eyes" and to make sure that meals are visually appealing when presenting them to residents. She also recommends prioritizing the education of CNAs and caregiving staff to understand the role of nutrition and hydration in healing and rehabilitation so they are then able to pass on that education to the residents to effectively encourage them to eat and drink.
Adding the diagnoses of protein-calorie malnutrition generates revenue in post-acute and long-term care. This can help to provide expediate nutritional care and reduce negative outcomes such as falls and weight loss. Ensuring the diagnosis is obtained means that you'll have access to the appropriate funds to tackle the condition in the most effective way.
Vitamin D is very important and lack of it can be a huge problem in long-term care. We should assume that residents don't get enough sun in long-term care because they're all sitting inside and therefore are likely to suffer from vitamin D deficiency, so what do we need to do? Start by making sure their milk is vitamin D fortified. Almost every resident in long-term care would benefit from multivitamins with vitamin D just to cover that.
Janet says that the role of milk and dairy products is incredibly important, not just because of the vitamin D content or the calorie and fat content but because whole milk contains almost 8 grams of protein per cup. If someone is allergic to cows milk or doesn't like milk, you need to make a real effort to find a suitable replacement such as almond milk or milk with reduced casein. Failing this, there needs to be allowances made regarding the amount of meat on their plate to keep the resident's protein intake up.