Dietitians in Long-Term Care
Fifteen years ago, when I was an undergraduate student, I never remember any of my peers saying “When I graduate, I want to work in geriatrics!” or “When I graduate, I want to work in long-term care!” Working with children, sports nutrition, health promotion, clinical dietetics- those were the hot fields everyone was talking about.
I think a lot of us in long-term care and geriatrics stumbled our way into this field. But I’ve got to tell you- once you stumble in, you don’t ever want to get out. Working in long term care is a wonderful opportunity and such an awarding career. While not every patient you see in this field is an older adult, it’s primarily a field in geriatric nutrition.
Working with Older Adults
Working with older adults is a privilege. These patients have so much life experience and knowledge to offer you as a professional, sometimes you can wonder who is helping who. In 2014, 14.5% of the US population was aged 65 or older and this number is projected to reach 23.5% by 2060 (1). The field of geriatrics and long-term care is a field that will only continue to grow.
Older adults have higher rates of chronic disease. It is estimated that 60% of older adults have 2 or more chronic diseases. Common chronic diseases in this population include heart disease, cancer, chronic obstructive pulmonary disease (COPD), stroke, diabetes, and Alzheimer’s disease (1). These are all conditions the dietitian can help manage or in some cases even prevent. We know that chronic disease can affect quality of life and older adults in our country deserve to have the highest quality of life we can offer them.
What is Long-Term Care
Explained in the simplest manner, long-term care is a range of services provided to individuals who can no longer live independently. The U.S. Department of Health and Human Services defines long-term care as a range of services and supports one may need to meet their personal care; in particular, their Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs) (2).
Some, but not all, levels of long-term care include skilled medical care in addition to assistance with ADL and IADLs. Post-Acute Care is the type of care that provides skilled medical care after a hospital stay (3). The goals of long-term care are to support the older adult in sustaining their health and quality of life. Maintaining both independence and dignity for the older adult are of the highest importance.
Long Term Care Settings and Services
Long-term care is offered in a multitude of settings and can often start at home. There are home health agencies that can come into the home of an older adult and provide medical, nursing, social, or other therapeutic treatments including medical nutrition therapy (3). Common types of home care include Medicare’s Home Health program and the Department of Veteran Affair’s Home Based Primary Care program.
Often times, when the everyday responsibilities of taking care of a home can be too much, an older adult will move into a retirement community. They may live independently in an apartment like setting, but can go down to a dining hall for daily meals. If there comes a time that they are no longer able to function independently in this setting and they need just a little more help, they can move into an assisted living facility where they receive help with their ADLs and IADLs (3). Retirement and assisted living facilities are both types of long-term care.
Skilled nursing facilities are the long-term care setting that provides the highest level of care for older adults. Skilled nursing facilities provide around the clock skilled care. These facilities are designed for older adults with complex medical needs (3). Some older adults may live in a skilled nursing home long enough to improve function and move back to a lower level of care, like an assisted living facility or their home. Other older adults may spend their final days in a skilled nursing facility setting.
A program that provides skilled care, but is primarily designed to keep older adults out of skilled nursing facilities, is most commonly known as PACE (Program of All-Inclusive Care for the Elderly). This program is funded through the Centers for Medicare and Medicaid Services and specific services offered vary by individual state. Common services covered by PACE include home care, hospital care, meals, nutritional counseling, etc. (3).
Other types of services offered long-term care settings include memory care, adult day care, and hospice programs. Memory care facilities function similarly to assisted living facilities but in a locked down setting for the safety of the older adult. Adult day care provide assistance with ADLs, socialization, meals, and respite for the caregivers of older adults in the program. Hospice provides support and care offered at very end of life. Hospice care can be provided at home or in a facility (3).
The Role of the Dietitian in Long-Term Care
The role of the dietitian in long-term care varies as different long-term care settings are bound to different regulatory requirements (3). However, dietitians can be found in all long-term care settings, even those without regulatory requirements mandating the presence or action of a dietitian. The role of the dietitian, regardless of setting, is almost always the same- manage overall nutrition care, prevent malnutrition, promote independent dining, and maximize quality of life.
Food is important at every stage of life. And it’s not just important for health- it’s important for socialization, emotional well-being, and quality of life. Foods served in all long-term care settings should be nutritious, flavorful, and look delicious. Older adults often have decreased appetite- especially those living in institutional settings (4). Serving the healthiest foods has no importance if the older adult doesn’t eat it.
It is the position of the Academy of Nutrition and Dietetics that “the quality of life and nutritional status of older adults in long-term care… can be enhanced by individualized nutrition approaches (3).” This means providing the least restrictive diet possible. “Least restrictive diet” is often referred to as a “liberalized diet” in every day practice.
Just because an older adult has diabetes does not mean they should automatically be put on an ADA diabetic diet or if they have heart disease should they be put on a salt restricted diet. Older adults have the right to choose between quality of life and improving health/increasing longevity (3). It is the role of the dietitian to provide education and support the older adult in their decisions.
The reason for liberalizing diets in older adults is two-fold- first, it is to respect their rights to make independent choices and second, it’s about focusing on total diet and the prevention of malnutrition in this high-risk population. Malnutrition is defined as: “Inadequate intake of protein and/or energy over prolonged periods of time resulting in loss of fat stores and/or muscle stores, including starvation related malnutrition, chronic disease or condition-related malnutrition and acute disease or injury-related malnutrition (3).”
Malnutrition in the older adult comes with many grave consequences- from loss of independence, increased risk of falls, increased hospitalization, and increased risk of mortality. It is estimated that 47% to 62% of older adults in long term care are at risk for malnutrition (3). The dietitian plays a huge role in the identification, treatment, and prevention of malnutrition in older adults.
Many older adults do want to work on managing and controlling their chronic disease and having a dietitian available is of great benefit. Dietitians can support the older adult in reaching their individual health goals. They can provide assistance with feeding tubes, difficulty chewing and swallowing, unintended weight loss, need for adaptive eating devices, maximizing intake with cognitive decline, and nutrition at end of life. There is a great deal of opportunities for dietitians in long-term care.
Choosing Long-Term Care
For older adults choosing long-term care, it is important that they know their options. Not only what services are available, but how these services are paid for. Medicare, Medicaid, the Department of Veteran Affairs, and private insurance all have their own rules on what services are covered and how much is to be paid out-of-pocket (5). Long-term care insurance is also a good option to consider when planning ahead. When looking at options, be sure to look for services that include a dietitian on their team.
The field of long-term care for dietitians is expansive and continues to grow. As a long-term dietitian you can help an older adult in a skilled nursing facility get well enough to return home. You can help prevent and treat malnutrition while working with older adults in an assisted living facility. You can work with an older adult one-on-one in their own home. While long-term care may not have been the most talked about field in my undergraduate class, it’s certainly the field I hope to stay in.
RD Nutrition Consultants LLC, is the industry leader in Nutrition Consultant Services for Long-Term Care Facilities Nationwide. We specialize in providing contract Registered Dietitian services in a wide variety of healthcare and wellness organizations.
REFERENCES
1. Older Adults. Office of Disease Prevention and Health Promotion website. https://www.healthypeople.gov/2020/topics-objectives/topic/older-adults. Accessed May 5, 2019.
2. What is Long-Term Care? U.S. Department of Health and Human Services website. https://longtermcare.acl.gov/the-basics/what-is-long-term-care.html. Updated October 10, 2017. Accessed May 5, 2019.
3. Dorner B, Friedrich E. Position of the Academy of Nutrition and Dietetics: Individualized Nutrition Approaches for Older Adults: Long Term Care, Post-Acute Care, and Other Settings. J Acad Nutr Diet. 2018; 118: 724-735.
4. Niedert K, Carlson M. Nutrition Care of the Older Adult: A Handbook for Nutrition Throughout the Continuum of Care. 3rd ed. Chicago, IL: Academy of Nutrition and Dietetics; 2016.
5. Who Pays for Long-Term Care? Department of Health and Human Services website. https://longtermcare.acl.gov/the-basics/who-pays-for-long-term-care.html. Updated October 10, 2017. Accessed May 6, 2019.
