From the February Issue of JAMDA

Abstract

The prevalence of anorexia in nursing homes is high even though several possible causes are preventable, according to a longitudinal study that also showed excess mortality among patients with anorexia. “Scientific evidence indicates that a significant number of elderly in nursing homes fail to get proper amounts and types of food necessary to meet essential energy and nutrient needs,” Dr. Francesco Landi, a professor of gerontology and geriatrics at Catholic University of Sacred Heart, Rome, said in an interview. Dr. Landi and his colleagues examined baseline data from 1,904 nursing home residents enrolled in the U.L.I.S.S.E. study to determine the prevalence of anorexia, defined as nutrient intake below 70% of estimated needs. They also looked for factors correlated with anorexia and survival rates. U.L.I.S.S.E. is a prospective, 1-year observational cohort study of the quality of care for older patients in hospitals, in nursing homes, and at their homes in Italy. More than 12% (240) of the patients had anorexia. The risk was nearly double among patients who had behavioral problems, chewing problems, dementia, depression, and constipation, as well as among those taking proton pump inhibitors and opioids. The mortality rate among 1,490 patients scheduled for 1-year follow-ups was double among patients with anorexia. The 271 deaths that occurred included 33.9% of patients with anorexia vs. 15.9% of those without the condition. “Anorexia among elderly is common, under-recognized, and undertreated,” Dr. Landi said. “Mechanisms involved in the age-related physiopathological decline in appetite and food intake are multifactorial and not completely understood.” The researchers cited factors including declining taste and smell that make food no longer enjoyable and medications that may further impair these senses. Dentures or poor dental health can make chewing difficult. Also, loneliness and depression can lead to decreased appetite. Studies have shown that anorexia is prevalent among frail elderly subjects in nursing facilities, and impairments in wound healing, immune response to infections, coagulation capacity, gut function, and muscle mass are correlated with anorexia. “Anorexia needs to be considered as an important geriatric syndrome,” Dr. Landi said. “Anorexia is a clinically relevant problem that impacts morbidity, mortality, and quality of life. Nutritional variables are a cardinal component of comprehensive geriatric assessment. Early recognition and care planning can help to ensure appropriate and timely nutritional intervention.” ▸ Source: Prevalence and Potentially Reversible Factors Associated with Anorexia among Older Nursing Home Residents: Results from the ULISSE Project – Landi et al. A skilled nursing facility is perhaps the most error-prone medical workplace, especially when dealing with new residents, contended Richard W. Miles of Bella Vista, Ariz. The reasons include cognitive errors that result when hospital and nursing home physicians fail to communicate about necessary changes to a patient's treatment plan and when families and patients have low expectations about their care. Citing medical literature and individual physicians' experiences, Dr. Miles said that several other factors are at work, as well. For example, patients and families often mistakenly believe that all community-based physicians are adept in the long-term care setting and that various doctors typically work together to craft a care plan. These same families often enter nursing homes with negative attitudes toward the physician who assumes the patient's care. Dr. Miles said that nursing home physicians can identify and correct their own cognitive errors by recognizing various psychophysical principles. “It is critical that long-term care physicians maintain a zero tolerance for flawed treatments because ‘failure to speak up’ [about another physician's mistake] places the patient at risk, and tolerance has a cumulative effect on local standards of care,” he added. Dr. Miles suggested that training in the cognitive psychology of medical decision making should be a core requirement for becoming a Certified Medical Director. ▸ Source: The Psychophysics of Transition to Long-Term Care – Miles