Consultant pharmacists are now being held accountable for their role in assessing potential causes of and solutions to unexplained weight loss in the nursing home resident. Traditionally, consultant pharmacists have remained on the sidelines when it comes to nutrition issues, considering them more of a dietary/nursing problem. However, the revised Health Care Financing Administration (HCFA) survey procedures and their emphasis on use of 24 new quality indicators (QIs) is quickly and effectively changing that perception. Preventing or correcting weight loss in the elderly patient is a constant battle in the long-term care environment, and the lack of medications approved for geriatric anorexia, the high cost of nutritional supplements, and the skyrocketing costs of nutrition-related comorbidities often makes the battle seem like a losing one. Nonetheless, HCFA surveyors and facilities are now mandating that consultant pharmacists be held accountable for their role in assessing potential causes and suggesting possible solutions for unexplained weight loss in the nursing home resident. Additionally, continued concerns regarding cost containment in the Medicare prospective payment system (PPS) environment are requiring that consultant pharmacists take an active role in working as part of the interdisciplinary team to help defray a multitude of costs associated with poor nutrition.
Defining the ProblemBy far, the most common nutritional problem encountered in the nursing home is undernutrition and weight loss. The prevalence of undernutrition in nursing homes has been reported to range from 20%–54%, and albumin levels of less than 3.5 g/dL have been found in up to 43% of residents. While undernutrition in nursing home residents may be caused or exacerbated by numerous medical conditions (Table 1), there are also many treatable causes of undernutrition that can be identified (Table 2).
Facing the ConsequencesThe effect of undernutrition on increasing morbidity and mortality is well documented. Residents who are undernourished are more susceptible to pressure ulcers, cognitive abnormalities, anemia, and fatigue. In addition, poor nutritional status is linked to immune dysfunction, predisposing the resident to infections and increasing the potential for complication of these infections. Wound healing is slowed, and the fatigue and weakness accompanying malnutrition may decrease the resident’s ability to participate in activities of daily living (ADLs) and other activities, which, in turn, may lead to a viscious cycle of depression and further weight loss.Of particular interest to the consultant pharmacist is the potential impact of undernutrition on medication therapies. Because undernutrition is associated with a decrease in serum albumin, the pharmacokinetics and pharmacodynamics of highly protein-bound drugs may be altered in undernourished residents. Such drugs include several commonly seen in the nursing home (e.g., digoxin, benzodiazepines, carbamazepine, phenytoin, valproic acid). Once all treatable causes are identified and addressed, nutritional supplementation is usually the first-line intervention for undernourished residents. The goal of nutritional supplementation is to provide sufficient calories and amino acids to help the resident effectively build protein and regain body weight. Between-meal snacks and “super foods” dense in calories are often tried. In addition, the use of liquid oral supplements in an effort to meet residents’ protein and calorie needs is also commonplace in the nursing home. While beneficial in some residents, liquid oral supplementation has not been shown to be universally effective. Compliance with supplements, usually available only in 8-oz servings, is often poor, with many residents consuming little or none of the supplement offered. And, as any consultant pharmacist who sits at the nurses’ station to review charts knows, supplements arriving at the nursing station may not be distributed to the residents or may sit for hours until the busy nurse or certified nurse assistant has an opportunity to offer them to the residents. Often, staff may resort to offering the supplements at the same time as meals, which may, in turn, lead to the resident’s consumption of the supplement and neglect of the meal. Further complicating use of liquid supplements, many residents are very sensitive to volume and become easily satiated. Liquid supplements are often just too much volume for these residents to consume, especially if they are then expected to eat a meal. In many instances, the use of liquid supplements may actually decrease overall intake. This problem of volume sensitivity in many nursing home residents has led to the recent development of new nutritional products that are able to pack more calories into lesser volume (see related article).
Because undernutrition is associated with a decrease in serum albumin, the pharmacokinetics and pharmacodynamics of highly protein-bound drugs may be altered in undernourished residents. Drug Therapy OptionsWhile there currently is no pharmacologic agent approved by the Food and Drug Administration (FDA) for management of geriatric undernutrition, several agents are commonly used in the nursing home in an effort to increase appetite. Megestrol acetate (Megace) is FDA approved for AIDS- and cancer-related anorexia and cachexia.While there are some small clinical trials that have shown Megace to help improve food intake in elderly patients, a definitive, sufficiently large clinical trial focusing on the effects of Megace in the elderly has yet to be completed. In addition, there appears to be a lack of consensus among prescribers regarding appropriate dosing of Megace. Some prescribers prescribe 40 mg q.i.d. (the dose used in a clinical trial of cancer patients), while others prescribe 400–800 mg/day, the dose recommended for AIDS patients. While generally well tolerated, Megace can contribute to delirium in the elderly and has been associated with thromboembolic events, which actually may be caused by the dehydration or malnutrition of the patient and not the drug. Although not approved for use in anorexia, Periactin (cyproheptadine), an antihistamine, has also been used to stimulate appetite. Like the other nonselective antihistamines (diphenhydramine, hydroxyzine), cyproheptadine is highly anticholinergic and clinically contraindicated, and therefore included on HCFA’s list of “Potentially Inappropriate Drugs.” Elixirs containing B vitamins and minerals (e.g., Eldertonic, May-Vita) are also commonly used in the nursing home population for appetite stimulation. While the B vitamins may provide some benefit to the resident’s overall nutritional status, most clinicians agree that the appetite-stimulating properties of these elixirs may be attributed at least in part to their 13% alcohol content, which may make them inappropriate for use in many patients.
Nutrition and the Survey ProcessThe recent changes to the HCFA survey process also highlight the importance of the consultant pharmacist assessing the resident’s nutritional status. One of the new survey protocols includes identification of residents with unintended weight loss (task 5C), and the investigative protocols for unintended weight loss mention numerous medication classes as risk factors. In addition to looking at assessments by the dietitian and nursing staff, surveyors are instructed to assess the adequacy of the drug regimen review in addressing medication therapies as both causes and solutions for changes in nutritional status. Pharmacists are expected to identify potential drug-food interactions, as well as to recognize the potential drug implications of physiologic changes such as dry mouth or alterations in appetite. Equipped with the HCFA list of “Drugs with Potential for Severe Adverse Drug Reactions,” surveyors will seek to determine if any of the residents’ current medications could contribute to the potential for weight loss.Much about the resident’s nutritional status can be gleaned from Minimum Data Set (MDS) data. Section K of the MDS provides explicit information about recent weight changes, difficulties chewing or swallowing, and consistent patterns of leaving meals uneaten. It also provides information regarding nutritional interventions, including use of feeding tubes, therapeutic diets, and between-meal dietary supplementation. Other sections of the MDS collect information regarding parameters that affect or are affected by nutrition, including fluid status, skin condition, cognitive patterns, and mood and behavior (Table 4). The MDS can trigger the need to complete a Resident Assessment Protocol (RAP); three of the 18 RAPs are nutritionally oriented.
HCFA QI 13, “prevalence of weight loss,” reflects the number and percentage of residents who have had a weight loss of 5% or more in the last 30 days or 10% or more in the last six months. Certain conditions are targeted as potential threats for weight loss, and surveyors are instructed to determine if the facilities have appropriately assessed residents falling into these categories. These conditions include:
This assessment by the facility is important in two areas of the survey process. First, if the facility fails to assess the risk for weight loss, and the loss is considered severe, not only will the problem fall into the area of nutrition, it could also affect the area of comprehensive assessments.
The Bottom LineIn addition to its many effects on nursing facility residents’ clinical outcomes and well-being, the impact of the resident’s nutritional status also translates into dollars and cents.Poor nutrition may cause slowed healing processes, lessening of skin integrity, and a decrease in physical activity that sets the stage for skin tears and pressure ulcers. This translates into additional cost in nursing time to care for the wounds and an increased need for supplies, and, oftentimes, necessitates the use of expensive wound treatment medications, all of which can place a major financial burden upon the facility. Pressure ulcers are also considered by HCFA to be a “sentinel event” QI. Therefore, not only could a survey deficiency citation for undernutrition create a financial burden during the survey process if a fine is levied, but it could actually precipitate the survey process in facilities failing to meet the QI criteria. Additionally, civil suits for pressure ulcers and falls are becoming more common in the long-term care setting, with nutrition often implicated. Even when considering only the impact of nutrition on pressure ulcers and falls, it quickly becomes obvious that adequate nutrition can result in huge cost savings for the nursing facility, which, in the current PPS environment, is a primary concern. As long-term care facilities become ever more vigilant about trying to prevent the negative outcomes associated with weight loss, consultant pharmacists will find themselves no longer able to sit on the sidelines when it comes to nutrition issues. Facilities and surveyors alike are now looking upon nutritional assessment as part of consultant pharmacists’ core responsibilities, requiring their active participation in the ongoing monitoring and evaluation of residents’ nutritional status. While many consultant pharmacists may not tend to think of themselves as nutrition experts, it has become clear that we not only can—but must—enhance our skills and develop the tools we need to play a significant role in assessing potential causes of undernutrition and weight loss and in recommending therapies, both pharmacologic and nonpharmacologic, that can assist in weight stabilization, decrease undernutrition-related comorbidities, and improve the quality of life for the residents we serve. Jan Allen, RPh, FASCP, is Vice President, National Accounts, GeriMed, Wetumpka, Alabama. Caren McHenry Martin, PharmD, is Consultant Pharmacist, Neil Medical Group, Greensboro, North Carolina.
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