Therapeutic strategies for managing undernourished institutionalized older adults are similar to those used within the community, though perhaps due to readily available medical supervision, enteral and parenteral modes of feeding are used more often. The comparatively formal structure of the nursing home environment has the added advantage of encouraging closer supervision of therapy and stricter nutritional surveillance.
A major drawback to oral nutritional repletion in institutionalized older persons is the restricted variety of meals. This can usually be circumvented by involving the residents in menu development and, where feasible, granting permission for meals of the residents' choice to be supplied by family or friends. Residents of nursing homes are often less functional than their peers and thus may be more dependent on assistance for their basic activities of daily living. When the ability to self-feed is compromised, it is imperative that all meals are supervised and assistance with feeding rendered where necessary. Many residents are persistent wanderers, and may expend a considerable amount of energy in this exercise. In such patients an appropriate increase in their daily energy intake is required to prevent weight loss. Similar adjustments may be required for residents with persistent involuntary movements or severe agitation.
Long-term care institutions must preserve the social and recreational aspects of meals; all too often, mealtimes are reduced to clinical, sanitized, and isolated events. Within the nursing home environment mealtimes are best managed as a component of recreational therapy. Socialization and the preservation of each resident's dignity should be encouraged during meals. Nursing facilities should also attempt to mimic community resources by making food items available outside scheduled mealtimes, from vending machines and snack carts.
Nutritional surveillance programs are crucial to the success of established intervention strategies within nursing homes. Quality indicators, preferably employing anthropometric indices, should be defined to monitor the success of intervention strategies. Continuous quality improvement and total quality management programs must also be implemented as critical components of effective nutritional intervention strategies. Finally, the development of nutrition focus groups and the use of interdisciplinary intervention strategies directed at increasing nutritional intake and preventing under-nutrition should be encouraged.
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