Journal of Gerontological Nursing

Feature Article 

Implementation and Effects of a Medication Pass Nutritional Supplement Program in a Long-Term Care Facility: A Pilot Study

Michelle Doll-Shankaruk, BSc, RD; Walter N.C. Yau, BSc, RD; Carol Oelke, RN

Abstract

The purpose of this 6-month study was to determine the most effective method for implementing an interdisciplinary medication pass nutritional supplement program in Extendicare’s long-term care facilities in western Canada by piloting the program in one facility. The program’s effects on residents’ body weight, skin integrity, and laboratory values related to nutritional status were evaluated. Resident adherence and staff perception were also assessed. Findings indicated that most residents experienced weight gain and improved visceral protein status. Resident adherence to the program was 96%, and staff feedback was positive. The promising results of this pilot study suggest that a medication pass nutritional supplement program could help improve the nutritional status of long-term care residents, thereby resulting in improved quality of life.

Abstract

The purpose of this 6-month study was to determine the most effective method for implementing an interdisciplinary medication pass nutritional supplement program in Extendicare’s long-term care facilities in western Canada by piloting the program in one facility. The program’s effects on residents’ body weight, skin integrity, and laboratory values related to nutritional status were evaluated. Resident adherence and staff perception were also assessed. Findings indicated that most residents experienced weight gain and improved visceral protein status. Resident adherence to the program was 96%, and staff feedback was positive. The promising results of this pilot study suggest that a medication pass nutritional supplement program could help improve the nutritional status of long-term care residents, thereby resulting in improved quality of life.

Ms. Doll-Shankaruk is a Registered Dietitian, Mr. Yau is Senior Dietary Consultant, and Ms. Oelke is Director of Care, Extendicare Holyrood, Edmonton, Alberta, Canada.

The authors thank Novartis Nutrition Canada for its donation of Resource 2.0 to this pilot study.

Address correspondence to Michelle Doll-Shankaruk, BSc, RD, Registered Dietitian, Extendicare Holyrood, 8008-95 Avenue, Edmonton, Alberta, Canada T6C 2T1; e-mail: michdoll@hotmail.com.

Malnutrition is a well-documented problem for residents in long-term care facilities. It has been estimated that 35% to 85% of long-term care residents are malnourished (Greene Burger, Kayser-Jones, & Prince, 2000; Keller, 1993; Laporte, Villalon, & Payette, 2001; Nutrition Screening Initiative, 2002). Risk factors for poor nutritional status in older adults include cognitive impairment, inability to self-feed, multiple comorbidities, social isolation, poor oral health, polypharmacy, and depression.

Weight loss and malnutrition can negatively affect quality of life and have been associated with diminished muscle strength, increased risk of pressure ulcers with decreased wound healing, and compromised immunity (Bergstrom & Braden, 1992; Ferguson, Cook, Rimmasch, Bender, & Voss, 2000; Horn et al., 2004; Keller, 1993; Lesourd, 1997). It has been found that hospital patients who are malnourished have increased morbidity and mortality and longer lengths of stay than those who are well nourished (Chima et al., 1997; Sullivan & Walls, 1999; Xakellis & Frantz, 1996). To optimize quality of care while maintaining cost effectiveness, timely and aggressive nutritional interventions should be promoted in long-term care facilities.

Background

Clinicians prefer a “food first” approach to nutrition therapy that emphasizes food intake. Although nursing staff spend a great deal of time encouraging and assisting long-term care residents to eat, inadequate intake of calories, protein, vitamins, minerals, and fluid is common. When poor dietary intake and weight loss occur, interventions may include snacks; small, frequent meals; liberalized diets; appetite stimulants; and oral nutritional supplements (Kayser-Jones et al., 1998; Turic, Lowry Gordon, Craig, Gonyon Ataya, & Coble Voss, 1998).

The advantages and disadvantages of using traditional supplements with meals or snacks have been debated (Bourdel-Marchasson et al., 2000; Elmstahl & Steen, 1987; Kayser-Jones et al., 1998; Lauque et al., 2000, 2004; Milne, Avenell, & Potter, 2006; Turic et al., 1998). Extra calories from supplements may make the difference between an intake that results in weight loss and one that helps maintain or increase weight. The typical volume of supplement provided may be filling in itself or difficult for residents to finish. This, in turn, may negatively affect food intake during meal and snack times.

Several years ago, the idea of dispensing a small amount of calorically dense oral nutritional supplement with the routine medication pass was introduced as a strategy for improving supplement acceptance and adherence in residents of long-term care facilities (Kerrigan, Maxwell, & Siegei, 1996). A nutrient-dense supplement that provides 2 calories/mL given as a medication pass program may have a greater effect on resident weight gain than does a traditional 1.06 calories/mL supplement provided with or between meals.

Small volumes of a nutrient-dense supplement provided often will have a minimal effect on appetite and will maximize food intake.

It is believed that small volumes of a nutrient-dense supplement provided often will have a minimal effect on appetite and will maximize food intake during meals and snacks. This delivery method allows professional nurses to observe and document supplement consumption and yields possible cost savings by reducing supplements wasted because they are served but not consumed. By incorporating this strategy into time already spent by professional nurses in medication administration, the time spent by nursing aides in helping residents with supplement intake is reduced. During the past several years, this method has been gaining popularity in long-term care facilities, and some literature supports its effectiveness in promoting weight gain or maintenance (Bender, Pusateri, Cook, Ferguson, & Hall, 2000; Kerrigan et al., 1996; Lewis & Boyle, 1998; Remsburg, Sobel, Cohen, Koch, & Radu, 2001; Robinson, 1997; Welch, Porter, & Endres, 2003; Yen, 1998).

In Extendicare’s long-term care facilities in northern Alberta, Canada, residents who are assessed as appropriate to receive nutritional supplements are generally provided 125 mL of a traditional 1.06 calorie/mL supplement three times each day during snack times. Reported supplement waste and inconsistent resident adherence to the current regimen have been of concern.

The purpose of this study was to determine the most efficient and effective method for implementing an interdisciplinary medication pass nutritional supplement program (MPNSP) in Extendicare’s long-term care facilities in western Canada by piloting the program in one facility. In addition, the objective was to evaluate the effects of the MPNSP on residents’ body weight, skin integrity, and laboratory values related to nutritional status. Resident adherence and staff perception were also assessed.

Method

Setting and Participants

This study was conducted in an 83-bed long-term care facility located in Edmonton, Alberta, Canada. The facility Registered Dietitian (M.D.-S.) and Director of Care (C.O.) screened all residents to determine eligibility for program participation. A total of 11 residents were selected to participate in the study. Residents who were receiving palliative care were excluded. Criteria for study inclusion were one or more of the following characteristics:

  • Undesirable significant weight loss unrelated to change in fluid status (5% or more in 1 month, 7.5% or more in 3 months, or 10% or more in 6 months).
  • Consistent inadequate intake of 50% or less of meals.
  • Conditions that increase metabolic needs, such as wounds, infection, trauma, fracture, or surgery.

Measures

Baseline and monthly weights were taken during this 6-month pilot study. Weight was measured with a standard balance during each resident’s first bath of the month. A resident was reweighed if there was a difference of 3 kg or more from the previous month’s weight. Two biochemical measures of visceral protein status—serum albumin and total protein—were obtained for each participant during the month prior to study initiation and again during the month after the 6-month study period using standard methods. Skin integrity was determined prior to study initiation and after study completion using monthly wound reports prepared for the health region.

Resident adherence was quantified by a review of documentation on the monthly medication administration records for each participating resident. Staff perception was determined with a feedback survey consisting of six open-ended questions with additional space for unstructured comments. The survey was provided immediately after the study period to all day and evening shift RNs holding a full-time or part-time position. Night shift RNs did not administer the supplement and were therefore excluded from the survey.

Procedure

This pilot study was approved by Extendicare (Canada) Inc.’s Western Operations Committee. This committee consists of the Vice President, Regional Directors, Long-Term Care Consultants, and other consultants, and when necessary, it serves as an Institutional Review Board to review and approve proposals for program changes in facilities. In addition, the long-term care facility’s Professional Advisory Committee, consisting of the Medical Advisor, Pharmacist, Director of Care, and ad hoc nursing and other therapies staff, approved the pilot study. Informed consent was obtained prior to initiation of the pilot study from each participating resident or the resident’s legal guardian. The facility pharmacist reviewed each participating resident’s medication profile for potential food-drug interactions, and none were found.

The protocol used a nutrient-dense supplement called Resource 2.0 (Novartis Nutrition Canada) that provided 2 calories/mL. The product was selected on the basis of its superior taste, convenient packaging compared with other similar products, and availability through the facility’s purchasing contract. The manufacturer was approached for financial support of the study and subsequently donated an approximate 5-month supply of Resource 2.0 at no cost to the facility during the course of the pilot study. Neither the facility nor the authors benefited in any other way from Novartis Nutrition Canada.

The Registered Dietitian and the Staff Development Coordinator conducted 20-minute inservice sessions for nursing, dietary, and management staff during the month prior to study initiation. The prevalence and consequences of malnutrition in long-term care residents were reviewed, as well as the purpose, potential benefits, and proposed protocol for the MPNSP pilot study. The supplement manufacturer’s area representative, a registered dietitian, also attended the inservice session to provide staff with a demonstration of the optimal method of thickening the supplement for those residents who require thickened fluids because of dysphagia. Staff were encouraged to taste the supplement and had the opportunity to ask questions and provide suggestions for the pilot study procedure.

The RNs dispensed 60 mL (2 fluid ounces) of Resource 2.0 with medications four times per day at 9:30 a.m., 1:00 p.m., 6:00 p.m., and 7:30 p.m. This protocol is similar to that used in previous articles that describe the MPNSP. The RNs observed the residents’ supplement consumption and documented intake in the medication administration records. If the medication was scheduled to be administered during mealtime, the medication with supplement was not provided until after the resident had finished eating, to ensure supplement consumption did not interfere with food intake.

During the pilot study period, 89% of the participating residents had an increase in body weight.

RNs strongly encouraged residents to consume the entire amount offered. Progress notes were written in the residents’ charts if the supplement was refused or not provided for any reason. Participation in the program was identified in the residents’ care plans. Fortified foods or beverages provided as part of a high-energy, high-protein diet were continued during the pilot study period, but traditional supplements were discontinued during the study period. The previous typical nutritional supplement regimen of 125 mL of a 1.06 calorie/mL supplement three times per day provided 398 calories and 15 grams of protein and cost approximately $0.94 per resident per day. The MPNSP regimen of 60 mL of Resource 2.0 four times per day provided 480 calories and 21 grams of protein and cost approximately $1.66 per resident per day.

Results

Of the 11 residents selected, 2 died during the pilot study period. The results presented below are for the 9 residents who completed the study. Because this was a pilot study with a very small sample, no inferential statistics were calculated. Only descriptive data are presented.

Resident Characteristics

All of the participating residents were women. Their mean age was 88 (age range = 80 to 99). Seven of the 9 residents were diagnosed with dementia, and 2 were diagnosed with diabetes mellitus. Eight participating residents received a mechanically altered diet, and 4 received thickened fluids because of dysphagia. Prior to the pilot study, all participants had received 125 mL of a traditional 1.06 calorie/mL supplement three times each day at snack times as part of a high-energy, high-protein diet. All but 2 of the residents were dependent on staff for feeding assistance.

The residents received an average of nine medications per day. Two of the residents were diagnosed with osteoporosis and as a result received a daily multivitamin as a source of vitamin D. RNs administered the supplement alone during some of the MPNSP provision times because not all of the participating residents were scheduled to receive medications four times per day.

Effects on Body Weight, Skin Integrity, and Laboratory Values

During the pilot study period, 8 (89%) of the participating residents had an increase in body weight, whereas 1 had a decrease in weight (Table 1). On average, the weight increase was 2.6 kg or 6.4% of body weight over 6 months. Three of the 9 participants had a significant weight gain of 10% or more in 6 months. As suggested by the Omnibus Budget Reconciliation Act of 1987, significant weight gain was considered to be 5% of body weight in 30 days, 7.5% in 60 days, or 10% in 180 days. Of the participants who experienced weight gain, the average gain was 3.5 kg or 8% of body weight.

Residents’ Monthly Weight

Table 1: Residents’ Monthly Weight

At the initiation of the study, 4 participants had a chronic pressure ulcer, defined as one that remained unresolved after 28 days. Of the four ulcers, two were assessed as Stage I and two as Stage II, using the National Pressure Ulcer Advisory Panel (2007) staging criteria. At the conclusion of the study, all pressure ulcers were healed.

Six (67%) of the participating residents’ albumin levels increased during the study period, 2 residents’ levels (22%) decreased, and 1 (11%) remained the same (Table 2). Prior to initiating the study, only 44% of the residents had albumin levels within normal limits. At the end of the study period, 67% of the participants had albumin levels within normal limits.

Residents’ Biochemical Data

Table 2: Residents’ Biochemical Data

Seven (78%) of the 9 participating residents’ total protein levels increased during the study period, and 2 residents’ levels (22%) decreased. Prior to initiating the study, 33% of the participating residents had total protein levels within normal limits. After study completion, 44% of participants had total protein levels within normal limits.

Resident Adherence

Resident adherence to the program was very high. Each resident received the supplement approximately 120 times per month, based on provision four times per day. Residents consumed the supplement an average of 115 times per month (96%). Reasons for residents not consuming the supplement were documented and included refusal, feeling unwell, or sleeping. RNs reported that a few residents required encouragement to take the supplement, while others enjoyed and even requested it. A few residents commented that the supplement tasted “too sweet.”

Staff Perception

Of the 9 RNs who were provided with a feedback survey after the pilot study period, 6 (67%) completed and returned the survey. Feedback from the RNs was positive. All respondents reported they believed the MPNSP had benefited the residents’ nutritional status and preferred that it be continued for residents at high nutritional risk. An increase in workload of 5 to 20 minutes per medication pass was reported. This was due to the RNs dispensing the supplement, thickening the supplement when required, and providing feeding assistance of the supplement to some residents.

Discussion

The resident participants in this MPNSP pilot study were primarily selected for meeting the criteria of weight loss and poor dietary intake. Prior to study initiation, these residents had already been receiving fortified foods and were on a traditional supplement regimen as part of a high-energy, high-protein diet. More than half of the residents had below-normal serum albumin levels, and more than two thirds had below-normal serum total protein levels, suggesting reduced visceral protein status.

Overall, the pilot study results indicated that participating residents experienced weight gain during the MPNSP study period. Weight records showed Resident A experienced a weight gain of 6.2 kg from April to May, despite the resident being reweighed. Nursing documentation indicated pitting bilateral foot edema during this time that was treated with a diuretic agent.

Participants who had chronic pressure ulcers prior to initiation of the study experienced resolution of their wounds during the study period. It should be noted that one resident who had a chronic Stage II pressure ulcer prior to study initiation was provided with a pressure reduction mattress during the study period, which promoted wound healing. The use of the pressure reduction mattress met wound care practice guidelines, which encourage a multifactorial approach in the treatment of chronic wounds. The majority of residents’ (67% to 78%) biochemical data suggested improvement in visceral protein status. Other factors that could affect this data include hydration status, malabsorption, inflammation, cancer, hepatic disease, and renal disease (Pagana & Pagana, 1998).

Resident adherence to the MPNSP was excellent at 96%, indicating very little of the supplement was wasted. This may be due, in part, to the RNs adapting the MPNSP to fit individual residents’ routines. For example, sometimes RNs reported “doubling up” the serving size of the supplement provided at 6:00 p.m. This was done if the resident was typically asleep during the next medication pass time of 7:30 p.m. and was not scheduled to receive any medications. This prevented unnecessary waking of the resident and demonstrated the need for individualized resident care to optimize quality of life.

Implementation of the MPNSP in the long-term care facility was very straightforward. Overall, staff was receptive to this new approach to prevent and treat malnutrition. Educating staff about malnutrition may have played a role in the favorable results. After the pilot study was completed, all surveyed RNs reported that they would prefer that the MPNSP be continued for those residents at high nutritional risk. The RNs reported that consistent monitoring and documentation of supplement intake was a critical component of the MPNSP.

Overall, staff was receptive to this new approach to prevent and treat malnutrition.

During the 6-month study period, RNs and the Director of Care referred several additional residents to the Registered Dietitian for inclusion in the MPNSP. The MPNSP was initiated for a few other residents, although they were not included in this pilot study. Communication between nursing staff, the Director of Care, the Registered Dietitian, and the dietary department was imperative so residents’ appropriateness for participation in the MPNSP was monitored and regularly reassessed.

Conclusion

During the 6-month period of this pilot study, a MPNSP was associated with maintenance or increase in body weight, improved skin integrity, and visceral protein status among participants. The interdisciplinary program was feasible and well accepted by residents and staff. The promising results of this pilot study, along with current literature, suggest that a MPNSP could help improve the nutritional status of long-term care residents at high nutritional risk, thereby reducing morbidity and mortality and increasing quality of life. Future well-designed studies, such as randomized clinical trials, are needed to determine the outcomes of a MPNSP for long-term care residents at high nutritional risk.

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Residents’ Monthly Weight


Weight (kg) Weight Change (kg) Weight Change (%)
Resident April May June July August September October (April to October) (April to October)
A 39.4 45.6 43.2 42.6 42.4 42.1 42.4 3 7.6
B 51.9 50.8 51.2 52 52.3 53.9 54.5 2.6 5
C 38.5 37.2 36.9 37.4 37.6 37.6 39.3 0.8 2.1
D 65 65.4 62.9 65 62.7 60.4 60.6 –4.4 –6.8
E 37.8 41.3 40.9 40.7 39.7 43.4 42.9 5.1 13.5
F 35.7 38.8 41.2 42.2 42.4 43.6 41.6 5.9 16.5
G 40.4 42.3 42.4 45.8 45.6 44 42.3 1.9 4.7
H 65.7 67.7 67 68.5 68.9 67.5 67.8 2.1 3.2
I 54.3 61.1 62.9 58 58.1 60.3 60.5 6.2 11.4
Average






2.6 6.4
Average for residents who gained weight






3.5 8

Residents’ Biochemical Data


Serum Albumin (g/L)
Serum Total Protein (g/L)
Resident April 2005 October 2005 Change (April to October) April 2005 October 2005 Change (April to October)
A 29 34 5 55 62 7
B 40 41 1 70 75 5
C 34 34 0 56 57 1
D 31 33 2 54 58 4
E 31 38 7 57 71 14
F 38 37 –1 66 65 –1
G 37 35 –2 65 60 –5
H 36 37 1 60 64 4
I 32 37 5 54 63 9
Average

2

4

Medication Pass Nutritional Supplement Program

2008. Implementation and Effects of a Medication Pass Nutritional Supplement Program in a Long-Term Care Facility: A Pilot Study. Journal of Gerontological Nursing, 345, 45–51.

  1. Weight loss and malnutrition can negatively affect quality of life and have been associated with diminished muscle strength, increased risk of pressure ulcers with decreased wound healing, and compromised immunity.

  2. During this 6-month pilot study, the medication pass nutritional supplement program (MPNSP) was associated with maintenance or increase in body weight, improved skin integrity, and visceral protein status among participants.

  3. The promising results of this pilot study, along with current literature, suggest that a MPNSP could help improve the nutritional status of long-term care residents at high nutritional risk, thereby reducing morbidity and mortality and increasing quality of life.

Keypoints

Authors

Ms. Doll-Shankaruk is a Registered Dietitian, Mr. Yau is Senior Dietary Consultant, and Ms. Oelke is Director of Care, Extendicare Holyrood, Edmonton, Alberta, Canada.

Address correspondence to Michelle Doll-Shankaruk, BSc, RD, Registered Dietitian, Extendicare Holyrood, 8008-95 Avenue, Edmonton, Alberta, Canada T6C 2T1; e-mail: .michdoll@hotmail.com

10.3928/00989134-20080501-02

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