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Undernutrition in Older Adults Across the Continuum of Care

Nutritional Assessment, Barriers, and Interventions


ELLEN F. FURMAN, BS, RN
ABSTRACT Undernutrition can be a signicant deterrent to healthy aging and can negatively affect health outcomes in older adults. Researchers have identied the prevalence of undernutrition in older adults and the need for intervention, yet the incidence remains high. The purpose of this article is twofold: to emphasize the need for nutritional assessment across the continuum of care as experienced by older adults, and to identify possible barriers to effective treatment. The assessment of nutritional status and the implementation of effective nutritional interventions are essential to the health of older adults. ging is not synonymous with poor health, despite popular societal belief. Often, pathological conditions are mistaken for aspects of normal aging, both by older adults and health care professionals. Undernutrition is one such pathological condition that may be disregarded because some of its symptoms are considered characteristic of normal aging (e.g., muscle wasting, weight loss). A missed diagnosis of undernutrition can lead to complex and chronic illness, with serious effects on an older adults physical and emotional resources, as well as on health care resources. Thus, patients and primary care providers must be aware of signs and symptoms of disease versus aspects of normal healthy aging. In this article, the need for nutritional assessment across the continuum of care is addressed, and ing to the literature, the prevalence of undernutrition, in older adults ranges from 5% (Sullivan, 2000) to 85% (Kayser-Jones, 2000), depending on the studys setting. Researchers also indicate that undernutrition contributes to older adult functional disability (Gary & Fleury, 2002), physical complications (Sullivan, 2000), morbidity and mortality (McCool et al., 2001), longer length of stay in hospitals (Gary & Fleury, 2002), and increased admissions to long-term care facilities (Gary & Fleury 2002; Huffman, 2002). Symptoms such as increased infection, electrolyte imbalance, altered skin integrity, anemia, generalized weakness, and fatigue have all been associated with undernutrition (Burger, KayserJones, & Bell, 2001). Additionally, the weakness and fatigue associated with undernutrition may also predispose older adults to periods of prolonged inactivity which, subsequently, can result in further complications. These facts, combined with the increase in the older adult population predicted during the next few decades, suggest that undernutrition could become a more extensive problem in the coming years. Also noteworthy is the increased incidence of chronic disease in the older adult population. Chronic disease may cause increased dysfunction in older adults, which also may affect their nutritional status (Gary & Fleury, 2002). Regardless of whether chronic disease contributes to undernutrition or undernutrition exacer-

barriers to effective treatment of undernutrition are identied. BACKGROUND Undernutrition is a broad term meaning conditions that occur when the intake of dietary nutrients are less than adequate to sustain health. Undernutrition is referred to throughout the literature as malnutrition, protein energy undernutrition (PEU), protein energy malnutrition (PEM), or protein calorie malnutrition (PCM), often without distinction (KayserJones, 2000; McCool, Huls, Pepones, & Schlenker, 2001; Stechmiller, 2003; Xaverius, Altus, & Mathews, 1999). In this article, the term undernutrition will be used to incorporate all of these more specic terms. Researchers have found that undernutrition is a signicant problem in the older adult population. Accord-

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bates chronic disease, prevention and treatment remain essential. Modied Food Pyramid for 70+ Adults Realizing that older adults have unique nutritional needs has led to S Calcium, vitamin D, the development of a modied food vitamin B12, and pyramid for older adults (Russell, Rassupplements mussen, & Lichtenstein, 1999). This pyramid (adaptation represented in the Meat, poultry, sh, dry Fats, oils and sweets Figure) acknowledges the reduced enerbeans, eggs and nuts use sparingly gy needs of older adults and recognizes group 2 servings the need for increased micronutrients and hydration as compared to younger Fruit group Milk, yogurt and adults. Health care professionals, hav 2 servings cheese group ing also realized these unique needs, 3 servings use a variety of nutritional assessment tools across health care settings to Bread, fortied Vegetable group cereal, rice and pasta 3 servings identify older adults who are undergroup 6 servings nourished or at risk for becomOriginal Food Guide Pyramid Water > ing undernour8 servings ished. Despite Fats, oils and sweets S these efforts, use sparingly older adults Figure. Original and modied food pyramids. Meat, poultry, sh, Milk, yogurt and continue to ex- cheese group dry beans, eggs and nuts group perience under- 3 servings 2-3 servings nutrition within Vegetable Fruit group the community, group 2-4 servings in the acute care 3 disabilities may (McCool et al., 2001) has developed a hospital setting, servings limit both the questionnaire that enables older adults Bread, and in long-term acquisition and to self-assess if they are at risk for undercereal, rice care facilities. nutrition. The NSI has also developed a preparation of and pasta group second tier of its screening tool, which food (Chen et al., 6-11 servings includes more comprehensive indica2001; Position of tors of undernutrition that may be used the ADA, 2000; NUTRITIONAL ASSESSMENT by primary care providers within comStechmiller, 2003). Social isolation can Undernutrition in Communitymunity settings (Gary & Fleury, 2002). lead to depression, which may inuence Dwelling Older Adults Additionally, the use of the Mini Nutriappetite (Chen et al., 2001; Stechmiller, It is estimated that 5% to 10% of tional Assessment (MNA) tool (Stech2003; Sullivan, 2000). Chronic health community-dwelling older adults are miller, 2003) has been used to identify problems may contribute to dysfuncundernourished (Sullivan, 2000). Cogtion or require special diets that affect undernutrition in the older adult popunitive changes in older adults may lead appetite (Callen & Wells, 2003). Older lation with high degrees of sensitivity, to missed meals (Chen, Schilling, & adults may have a limited income, specicity, and predictive value. AccordLyder, 2001; Kayser-Jones, 2000; Posiwhich could require they forego food ing to Stechmiller (2003), the MNA uses tion of the American Dietetic Associaor compromise on the nutritional value anthropometric measurements, dietary tion [ADA], 2000; Stechmiller, 2003). of foods (Position of the ADA, 2000; questions, general health questions, and Medications can inuence both feelings Xaverius et al., 1999). self-perceived health status questions to of satiation and absorption of nutriFailure to assess and treat undernutrievaluate nutritional status. ents (Chen et al., 2001; Position of the tion in community-dwelling older adults ADA, 2000; Stechmiller, 2003; Sullivan, can lead to both physical and functional Undernutrition in Hospitalized 2000). Changes in dentition or the abildisabilities that result in ad mission to Older Adults ity to swallow may alter an older adults acute care hospitals, long-term care faWhen an acute illness requires admiscapability to eat, thereby limiting nutricilities, or death. Two instruments may sion to a hospital, older adults may be at tional intake (Chen et al., 2001; Kayserbe useful for assessing undernutrition in increased risk for undernutrition and reJones, 2000; McCool et al., 2001; Stechcommunity dwelling older adults. The lated complications. It is estimated that miller, 2003; Sullivan, 2000). Functional Nutrition Screening Initiative (NSI), as many as 60% of older adults either

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CAUSES OF UNDERNUTRITION IN OLDER ADULTS


Acute illness Chronic illness Cognitive impairment Culturally unappealing foods Depression, loneliness, social isolation Financial limitations Functional disabilities Impaired dentition or ability to swallow

Lack of adequate staff or inadequate education of staff Medications Social conditions Unappealing environment Eating alone Eating in bed Unappealing taste or texture of foods

are undernourished upon admission to the hospital or become undernourished during their hospital stay (Gary & Fleury, 2002). Causes of undernutrition within this setting include many of the causative factors identied for community-dwelling older adults. In addition, the food served in hospitals may not be culturally appealing or may lack the taste or texture of the foods an older adult is accustomed to eating, thereby affecting intake. Further changes in physical and functional health status may inhibit or prohibit oral food intake. The need for continued nutritional assessment throughout older adults length of stay is necessary because changes in health may necessitate changes in nutritional therapies. Also, acute illness places an additional burden on older adults. During episodes of acute illness, physiological stress leads to catabolism which, subsequently, results in increased metabolic demands and a need for additional nutrition (Gary & Fleury, 2002). The presence of undernutrition has been associated with increased length of hospital stay, increased in-hospital morbidity, and increased complications, such as pressure ulcers and infections (Kamel, Karcic, Karcic, & Barghouthi, 2000). Studies also suggest that older adults who are undernourished at discharge are at increased risk for non-elective readmission to hospitals, as well as subsequent death (Sullivan & Walls, 1998). Despite these statistics, many older adults do not receive adequate nutritional assessment or treatment during their hospitalization (Kamel et al., 2000).

According to Gary and Fleury (2002), older adults are especially vulnerable because undernutrition occurs with less physiologic stress and in a shorter time than it occurs in younger adults. Thus, the assessment time is especially critical because of the current decreased length of hospital stays. However, if hospital stays are protracted because of a complex condition, older adults may become more profoundly undernourished and their clinical course may become more complicated because of their nutritional status. According to Gary and Fleury (2002), effective nutritional assessment tools for identication of nutritional status in hospitalized patients include the MNA and the Subjective Global Assessment (SGA). The SGA uses nutritional history, including dietary changes, as well as physical ndings to evaluate nutritional status (Persson, Brismar, Katzarski, Nordenstrom, & Cederholm, 2002).
Undernutrition in Older Adults Living in Long-Term Care Facilities

Long-term care facilities are thought to have the highest incidence of undernutrition of all settings across the continuum of care. It is reported that between 35% and 85% of nursing home residents are undernourished (Kayser-Jones, 2000). Factors contributing to undernutrition in this population include factors common to community-dwellers and hospitalized older adults. In addition, older adults residing in long-term care facilities often have increased physical, functional,

and cognitive decits (the primary reason for admission). Because of these impairments, older adults in long-term care facilities may require either partial or total assistance to eat. Kayser-Jones (2000) found nursing homes often were understaffed, and this resulted in residents receiving inadequate assistance with eating. Consequently, residents dietary intake was insufcient. Kayser-Jones also found that the percentage of food eaten and nutritional supplements consumed by residents was often erroneously reported, leading to a discrepancy between residents medical records and their clinical parameters. Other factors contributing to undernutrition in this setting include inactivity and lack of the social aspects of eating (e.g., eating alone in bed). These factors were believed to contribute to decreases in appetite and dietary intake. In this setting, undernutrition is often assessed using the Minimum Data Set (MDS). The MDS is completed for older adults upon their admission to a long-term care facility, and contains a nutritional assessment portion shown to be reliable as an assessment tool (Crogan, Corbett, & Short, 2002). Use of the MDS or certain MDS variables (e.g., weight loss, percentage of meals consumed, psychiatric diagnoses, functional disabilities, age) may be useful in identifying residents who are undernourished or are at risk for undernutrition. However, the MDS is not required to be fully completed until day 14 after admission. An additional tool that may be benecial in the assessment, treatment, and management of undernutrition in this setting is the clinical guidelines formulated by the Council for Nutritional Clinical Strategies in Long-Term Care (Thomas, Ashman, Morley, Evans, & the Council for Nutritional Strategies in Long-Term Care, 2000). This tool represents a multidisciplinary approach to managing undernutrition in long-term care and contains guidelines for dietary staff, nursing staff, dieticians, and physicians, as well as the Geriatric Depression Scale (Yesavage

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et al., 1982-1983) and the Cornell Scale for Depression in Dementia (Alexopoulos, Abrams, & Shamoian, 1988).
The Persistent Problem of Undernutrition

Despite all the information related to the known causes of undernutrition (Sidebar on p. 24), the known prevalence, the potential for increased incidence of undernutrition across the continuum of care, and apparently valid assessment tools, undernutrition continues to occur within the older adult population. Older adults are most often admitted to nursing homes from hospitals (44%), private residences (32%), and other nursing homes (12%). These older adults are most often discharged from nursing homes to hospitals (28%), die (27%), or move to other nursing homes (7.5%) (Gabrel, 1997). These data indicate that as older adults move along the continuum of care, they are often admitted and discharged into facilities in which the prevalence of undernutrition has been well documented. Therefore, failure to adequately assess, diagnose, and treat older adults at risk for undernutrition within each setting may perpetuate, and perhaps exacerbate, this problem. Why and how undernutrition continues to occur should be of great concern to health care professionals. Undernutrition has proven extremely costly to older adults in terms of disease trajectory, health outcomes, and health care use. Barriers to effective assessment, diagnosis, and treatment must be identied and overcome to help ameliorate this problem. Although further research is indicated, after reviewing the literature related to undernutrition in older adults, possible barriers are apparent. BARRIERS TO ADEQUATE NUTRITION
Unclear Denitions

tion to refer to undernutrition. Additionally, undernutrition may refer to the marasmus-type, the kwashiorkortype, a combination of both (Chen et al., 2001), or a deciency of micronutrients (McCool et al., 2001). Marasmus is the insufcient intake of calories and kwashiorkor is the insufcient intake of proteinsboth result in undernutrition. Chen et al. also questioned whether malnutrition is the process that occurs with poor dietary intake or the state an older adult reaches after being malnourished. Without a professional consensus related to terminology and denition, patients and health care workers may well be confused. Variable denitions also may compromise replication of research, necessary in the formulation of evidence-based clinical guidelines.
Lack of Diagnostic Criteria

tative of current best practice. However, lack of professional consensus related to diagnostic criteria makes development of standards for diagnosis and treatment difcult.
Confused Symptomatology and Comorbidities

Foremost among the barriers may be the variability of denitions related to malnutrition. The term malnutrition is ambiguous because it may refer to both overnutrition and undernutrition (Gary & Fleury, 2002). However, much of the literature uses malnutri-

Although nutritional assessment tools have been shown to be valid for use in identifying older adults at risk for undernutrition, no diagnostic tool has proven conclusive in its diagnosis. Measurement of body weight, body mass index (BMI), and other anthropometrical measures are often used to help diagnose undernutrition in older adults. However, changes in stature and loss of bone, tissue, and muscle mass (Gary & Fleury, 2002) that occur with normal aging can confound these data. Also, by the time changes in measures such as BMI indicate undernourishment, it may be advanced. Biochemical assessments have been used to help diagnose undernutrition. Examples of biochemical assessments include screening for serum proteins such as albumin, prealbumin, transferrin, and total cholesterol (Gary & Fleury, 2002). However, because albumin and transferrin have long half-lives, undernourishment may be quite advanced before it is detected. Comorbidites prevalent in older adults also have the potential to affect these serum values. Often, health care professionals will use a combination of diagnostic tools including weight, diet history, BMI, anthropometrical measurements, and biochemical values, which is represen-

Older adults and primary care providers may confuse symptoms of undernutrition with aspects of normal aging (e.g., decreased appetite, changes in satiation, muscle wasting). This may lead to under-reporting of symptoms or under-diagnosis. Weight loss may be insidious, and therefore, less alarming and less reportable by the older adult. The increase in chronic health problems and associated symptoms that occur in older adults may mask symptoms of undernutrition. Dementia may affect some older adults ability to provide a weight and diet history. Limited time during primary care appointments may require older adults to focus on issues that are the most problematic. During an acute care hospital admission, the plan of care may focus more on the condition that lead to the admission, rather than on a more holistic approach to care. The admission of the older adult to a long-term care facility may present additional risk because of older adults increased frailty and increased incidence of undernutrition in these facilities.
Fragmented Care

Another barrier to successful assessment, diagnosis, and treatment of undernutrition may be lack of coordination of care (Position of the ADA, 2000). Kowanko, Simon, and Wood (1999) found that nurses had knowledge decits and role conict related to various aspects of patient nutrition. Believing that the dietician is responsible for the nutritional care of older adults in hospitals and long-term care facilities can result in poorer care. The delegation of oral feeding to aides should not minimize the nurses role in the assessment of nutritional status. As at-risk and undernourished older adults move back and forth along the continuum of care,

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lack of methods to track interventions and outcomes limit the evaluation of treatment that would provide for a continued plan of care.
Lack of Treatment Options

Another barrier to adequate nutrition may be lack of treatment options. Primary care providers, unsure of an older adults disease trajectory, may delay changes in nutritional therapies. The invasiveness of a feeding tube may make placement a poor choice for both patient and primary care provider. Complications associated with long-term use of parenteral nutrition may limit use and, according to Bowers (1999):
The standard intravenous infusion of 100 to 150 grams of glucose in an electrolyte solution, does not meet minimal nutritional requirements for a 24 hour period, much less for days or weeks....and if the diet is signicantly inadequate for more than a few days catabolism begins (p. 147).

Therefore, should an older adults nutrition be deemed less than adequate for more than a few days, prompt implementation of nutritional therapy should be instituted to avoid further complications.
Medication Mismanagement

tion after at-risk older adults within the community are identied. Nutritional programs, such as the Elderly Nutrition Program, provide home delivered meals and congregate meals for older adults. These programs have been shown to improve nutritional intake (McCool et al., 2001). Social connectedness has been shown to positively inuence appetite (Callen & Wells, 2003); therefore, maintenance or establishment of social relationships should be encouraged. Oral examinations should be performed routinely. Educational programs for both older adults and caregivers should focus on the recommended intake of various nutrients, identication of nutrient dense foods, positive feedback for healthy food choices (Xaverius et al., 1999), and the use of nutritional supplements as indicated by the primary care provider. Primary care providers, pharmacists, nurses, and older adults must be aware of interactions between drugs, foods, and conditions, and prescribe, dispense, and administer appropriate medications accordingly.
Hospitalized Older Adults

Older Adults Living in Long Term Care Facilities

Some medications that cause anorexia or interfere with the absorption of nutrients may contribute to undernutrition. Commonly prescribed medications such as metformin, spironolactone, digoxin, amantadine, and uoxetine have been associated with anorexia, and antacids and antibiotics may contribute to malabsorbtion of nutrients (White & Ashworth, 2000). Also, pharmocokinetics are different in older adults and should be assessed on an individual basis (Edmunds & Mayhew, 2000). Polypharmacy, prevalent in the older adult population, must be assessed as an etiology of decreased appetite and weight loss. INTERVENTIONS
Community-Dwelling Older Adults

Undernutrition treatment must focus on the etiology of the condi-

After a nutritional assessment completed on admission has identied older adults at risk of becoming undernourished during their acute illness, early interventions should be aimed at reversing or preventing further decline. Therapeutic diets, diets of varying consistencies, small and more frequent meals, and dietary supplements may be used if the older adult is able to swallow and has a functioning gastrointestinal (GI) tract (Bowers, 1999; McCool et al., 2001). If the older adults ability to swallow or the gag reex is compromised, enteral feedings via feeding tube is an alternative therapy. Should an older adult have a non-functioning GI tract, parenteral nutrition should be started. The multidisciplinary team must consider the older adult holistically. Nutritional aspects of care are included in this holistic approach. Consultation among all team members throughout the nursing process is necessary so quality care can be provided.

Suggested treatments for undernutrition in this setting include: Specialized diets or discontinuation of dietary restrictions in an attempt to stimulate appetite. Nutritional supplements (Huffman, 2002). Increased dietary selections including more culturally appropriate meals. Increased staff and training of staff in the techniques of safe and effective feeding techniques. Designated areas for dining (Kayser-Jones, 2000). Enteral and parenteral nutrition (Bowers, 1999). An older adults willingness to eat, which affects appetite, has been associated with positive mood, independence, good health, well-prepared food, a clean and cheerful eating environment, and camaraderie with other residents (Wikby & Fagerskiold, 2004). Therefore, interventions implemented to maximize older adults independence and functionality as well as contribute to an aesthetic eating environment may improve appetite. CONCLUSIONS A dichotomy exists between knowledge and treatment of undernutrition in the older adult population. Although some symptoms of undernutrition may appear similar to characteristics of normal aging, health care professionals working with and caring for older adults should be expert in their abilities to holistically assess and diagnose symptoms of undernutrition. The increased prevalence of undernutrition in this population should substantiate screening practices that identify older adults at risk so preventative practices can be implemented before the condition becomes problematic. Awareness that undernutrition may be a prevailing problem or an underlying problem in older adults with other comorbidites should increase routine screening practices. Additionally, the screening and assessment of nutritional status must be ongoing, corresponding to changes in

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older adults physical, functional, and cognitive status. This requires a comprehensive assessment of all indicators of undernutrition throughout the continuum of care as experienced by older adults. Nutritional assessment tools are available and have been proven valid in identifying older adults who are undernourished or at risk for becoming undernourished. However, because no single diagnostic tool has been proven conclusive in the diagnosis of undernutrition, health care professionals must use a variety of available tools to ensure treatment is implemented promptly. This process must be well documented so the effectiveness of treatment can be evaluated as the older adult moves across the continuum of care. Failure to evaluate older adults nutritional history can lead to delayed treatment, which may result in poorer health outcomes. Research indicates that undernutriton contributes to unhealthy aging. Potential barriers to adequate nutrition must be overcome if older adults are to age healthily across the continuum of care. Older adults have unique nutritional needs and vulnerabilities and, therefore, nutritional status must be assessed continuously throughout their care. Further research is needed to identify why undernutrition continues to occur; barriers to treatment; implications in this population; and better methods to assess, diagnose, and treat this condition.
Alexopoulos, G.S., Abrams, R.C., Shamoian, C.A. (1988). Cornell Scale for Depression in Dementia. Biological Psychiatry, 23(3), 271-84. Bowers, S. (1999). Nutrition support for malnourished, acutely ill adults. Medsurg Nursing, 8(3), 145-165. Burger, S.G., Kayser-Jones, J., & Bell, J. P. (2001). Food for thought. Contemporary Long Term Care, 24(4), 24-28. Callen, B.L., & Wells, T.J. (2003). Views of community-dwelling, old-old people on barriers and aids to nutritional health. Journal of Nursing Scholarship, 35(3), 257-262. Chen, C.C.-H., Schilling, L.S., & Lyder, C.L. (2001) A concept analysis of malnutrition in the elderly. Journal of Advanced Nursing, 36(1), 131-142. Crogan, N.L., Corbett, C.F., & Short, R.A. (2002). The minimum data set: Predicting malnutrition in newly admitted nursing home residents. Clinical Nursing Research, 11(3), 341-353.

KEYPOINTS

UNDERNUTRITION IN OLDER ADULTS


Furman, E.F. Undernutrition in Older Adults Across the Continuum of Care: Nutritional Assessment, Barriers, and Interventions. Journal of Gerontological Nursing, 2006, 32(1): 22-27.

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Undernutrition can signicantly affect the health of older adults, and nurses must consider the unique nutritional needs of this population. Nutritional assessment of older adults occurs across the continuum of care, yet the incidence of undernutrition remains high. Nutritional assessment, treatment, and evaluation must be ongoing as older adults move across the continuum of care. Possible barriers to nutritional health must be overcome for older adults to maintain optimal health as they age.

REFERENCES

Edmunds, M.W., & Mayhew, M.S. (2000). Pharmacology for the primary care provider. St. Louis, MO: Mosby. Gabrel, C.S. (1997). Characteristics of elderly nursing home current residents and discharges: Data from the 1997 National Nursing Home Survey. Advance Data, 312, 1-16. Gary, R., & Fleury, J. (2002) Nutritional status: Key to preventing functional decline in hospitalized older adults. Topics of Geriatric Rehabilitation, 17(3), 40-71. Huffman, G.B. (2002). Evaluating and treating unintentional weight loss in the elderly. American Family Physician, 65(4), 640-650. Kamel, H.K., Karcic, E., Karcic, A., & Barghouthi, H. (2000). Nutritional status of hospitalized elderly: Differences between nursing home patients and community-dwelling patients. Annals of Long-Term Care, 8(3), 33-38. Kayser-Jones, J. (2000). Improving the nutritional care of nursing home residents. Nursing Homes Long Term Care Management, 49(10), 56-59. Kowanko, I., Simon, S., & Wood, J. (1999). Nutritional care of the patient: Nurses knowledge and attitudes in an acute care setting. Journal of Clinical Nursing, 8, 217-224. McCool, A.C., Huls, A., Pepones, M., & Schlenker, E. (2001). Nutrition for older persons: A key to healthy aging. Topics in Clinical Nutrition, 17(1), 52-71. Persson, M.D., Brismar, K.E., Katzarski, K.S., Nordenstrom, J., & Cederholm, T.E. (2002). Nutritional status using mini nutritional assessment and subjective global assessment predict mortality in geriatric patients. Journal of the American Geriatrics Society, 50(12), 1996-2002. Position of the American Dietetic Association: Nutrition, aging, and the continuum of care. (2000, May). Journal of the American Dietetic Association, 100(5), 580-595. Russell, R.M., Rasmussen, H., & Lichtenstein, A.H. (1999). Modied food guide pyramid

for people over seventy years of age. Journal of Nutrition, 129, 751-753. Stechmiller, J.K. (2003). Early nutritional screening of older adults. Journal of Infusion Nursing, 26(3), 170-177. Sullivan, D.H. (2000). Undernutrition in older adults. Annals of Long-Term Care, 8(5), 41-46. Sullivan, D.H., & Walls, R.C. (1998). Protein-energy undernutrition and the risk of mortality within six years of hospital discharge. Journal of the American College of Nutrition, 17(6), 571-578. Thomas, D.R., Ashmen, W., Morley, J.E., Evans, W.J., & the Council for Nutritional Strategies in Long-Term Care. (2000). Nutritional management in long-term care: Development of a clinical guideline. Journal of Gerontology: Medical Sciences, 55A(12), M725-M734. White, R., & Ashworth, A. (2000). How drug therapy can affect, threaten, and compromise nutritional status. Journal of Human Nutrition and Dietetics, 13(2), 119-129. Wikby, K., & Fagerskiold, A. (2004). The willingness to eat: An investigation of appetite among elderly people. Scandinavian Journal of Caring Science, 18, 120-127. Yesavage, Y.A., Brink, T.L., Rose, T.L., Lum, O., Huang, V., Adey, M., et al. (1982-1983). Development and validation of a geriatric depression screening scale: A preliminary report. Journal of Psychiatric Research, 17(1), 37-49. Xaverius, P.K., Altus, D., & Mathews, R.M. (1999). Malnutrition of elders: A review of the literature and suggestions for a comprehensive treatment program. Journal of Nutrition for the Elderly, 19(1), 41-47. ABOUT THE AUTHOR

Ms. Furman is Advanced Practice student, University of Massachusetts, Amherst. Address correspondence to Ellen F. Furman, BS, RN, 104 Wildower Circle, Westeld, MA 01085.

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