Nutritional assessment of residents in Long-Term Care Facilities (LTCFS): Recommendations of the task force on nutrition and ageing of the IAGG European Region and the IANA

Abstract

Unintentional weight loss and Undernutrition are major problems among older people living in Long-Term Care Facilities (LTCF). Undernutrition manifests in LTCF particularly as weight loss and low Body Mass Index (BMI) and is associated with increased morbidity and mortality as well as with functional decline. There are many factors associated with poor nutritional status and affecting protein-energy intake and/or energy expenditure. These include age of 85 years or older, low nutrient intake, loss of ability to eat independently, swallowing and chewing difficulties, becoming bed-ridden, pressure ulcers, history of hip fracture, dementia, depressive symptoms and suffering from two or more chronic illnesses. Nutritional evaluation is an essential part of the Comprehensive Geriatric Assessment (CGA). This evaluation ranges from methods such as BMI to several validated tools such as Mini-Nutritional Assessment (MNA). After diagnosis, the management of undernutrition in LTCF requires a multidisciplinary approach which may involve dietary and environmental improvements and managing multiple co-morbidities, while avoiding polypharmacy as far as possible. Finally, the need for supplementation or artificial (tube) feeding may be considered taking into account the CGA and individual needs. This document presents a succinct review and recommendations of evaluation and treatment of undernutrition.

Introduction

In Europe, approximately 5% of people aged 65 and older live in LTCF, Nursing Homes (NH) or Long-term Care Units (LTCU). Undernutrition is a major problem in LTCF due to its high prevalence, consequently increasing morbidity and mortality and decreasing quality of life (1). Undernutrition causes changes in body mass and composition which manifest particularly as weight loss and low BMI. Signs of undernutrition, such as low BMI, and low energy intake predict reduced physical performance (2) and functional decline (3). A U-shape relationship between energy intake and mortality has been shown in middle-aged men (4). Mortality was lowest in those whose energy intake was 15% below the group mean but increased in those for whom it was 50% lower than the group mean (4). A low BMI has also been found to have a negative impact on health-related quality of life among nursing home residents aged 65 and over (5).

Nutritional deficiency, though often unrecognised, is a potentially reversible cause of adverse clinical progression and outcome. The main problem, observed in several studies, is that participants have intakes below requirements. A detailed study in one LTCF showed that there was a high prevalence of inadequate intake; the mean energy intake was 1,164 kcal, and that even if the diet was entirely consumed, which would have provided the recommended energy intake, it did not provide the recommended levels of micronutrients (6). The prevalence of undernutrition varies from 36.6% to 85% depending on the study centre, type of measure and individual characteristics of the subjects studied. The type of facility and geography also affects the findings; being in an urban or large town, nursing home is also independently correlated with the prevalence of undernutrition (7, 8). Besides the low intake of macronutrients in LTCF, low intakes of micronutrients have been found, especially folic acid, other B-group vitamins (including B1, B6, B12 and riboflavin), vitamins A, C, D, E and K, selenium, zinc and iron (9, 10, 11, 12, 13).

This document sets out recommendations of the Nutritional Task Force of the International Association of Gerontology and Geriatrics (IAGG European Region) and the International Academy of Nutrition and Aging (IANA). A group of experts met in Barcelona in May 2004 with the aims of discussing the current situation and reaching a consensus on the management of nutritional problems in LTCF, especially in institutionalized elderly in Nursing Homes (NH) and Long-Term Care Units (LTCU).

It is based on current evidence in the relevant published literature on diagnosis, evaluation and treatment of undernutrition in this high risk population but is not meant to be an exhaustive review.

Methods

A search of the existing literature was conducted using the MEDLINE data-base (1965–2007). The key-words searched for were: Malnutrition [text word], Malnutrition [Mesh Term. All subheadings], Undernutrition [text word], Nutrition* [text word], Undernourished* [text word], Diet* [text word], Nursing home [text word], Nursing homes [text word], Long term care [text word], Food, fortified [Mesh terms], Enteral nutrition [Mesh terms], Assessment [text word] and Nutrition assessment [Mesh Terms]. The age limit set was 65 years and older. Searches were also conducted in the Cochrane Library and the National Guideline Clearinghouse.

The retrieved abstracts were read to obtain the most relevant articles, which were used to discuss the present recommendations.

Risk factors for weight loss and low BMI

A study using the Minimum Data Set (MDS), in USA nursing homes (14), found that the following factors were associated with both low BMI and weight loss: deficient oral intake, loss of ability to eat independently, pressure ulcers and chewing disorders. Additionally, age 85 or older, being female, being bed-ridden and having a history of hip fracture were identified as risk factors for low BMI, while depressive symptoms and having two or more chronic illnesses were found to increase the risk of weight loss (14). A further study using MDS data identified three predictor variables for weight loss: leaving 25% or more of the food uneaten in most of the main meals, receiving sedative drugs and not being able to eat independently (15). An association between poor mouth condition, low BMI and low albumin levels has also been reported (16).

In older people admitted to LTCF, many diseases and problems are associated with undernutrition including dementia, depression (14), decline in activities of daily living (ADL), loss of ability to eat independently, and especially swallowing disorders (17). The situation is further complicated by potential interactions between nutrients and the drugs used to treat multiple co-morbidities (18, 19). Table 1 summarizes the most important risk factors. Behavioral symptoms in Alzheimer’s disease such as agitation, aggression, lack of inhibition (20), increased mental disorganization and confusion (21) can lead to weight loss among institutionalized persons due to changes in eating patterns (21). Undernutrition and tube feeding are independent risk factors for pulmonary aspiration which further worsen the prognosis (22).

Table 1.

Main conditions associated with weight loss and low BMI

-Women -85 years and older -Low energy intake / Leaving 25% or more at most of main meals -Poor oral status and oral health problems (including chewing problems, pain in mouth, xerostomia, inadequate mouth hygiene, poor dentition) -Swallowing difficulties -Dependence for activities of daily living (especially loss of ability to feed independently) -Bed ridden -Co-morbidity (2 or more chronic diseases) -Dementia -Depression -Osteoporosis -Pressure ulcers -Hip fracture -Stroke -Faecal impactation -Infection -Cancer -Sedative drugs

Finally, the environment may play an important role in affecting appetite and increasing the risk of weight loss. Aspects of food presentation: lack of flavour and variety, inadequate consistency and temperature, can result in suboptimal food intake (23, 24). Changing to a well illuminated, socially pleasing, home-like environment has been shown to improve energy intake for cognitively impaired individuals with low BMI (25).

Nutritional assessment

People admitted to LTCF tend to have multiple co-morbidities, polypharmary and diverse levels of disability. Nutritional assessment plays an essential complementary role in the context of the Comprehensive Geriatric Assessment (CGA) for these people.

Anthropometric measures

Anthropometric measures (weight, BMI, arm circumference and skinfold measurements) are simple and cheap to use in LTCF. In the USA, the Omnibus Budget Reconciliation Act of 1987 (OBRA ‘87) established national minimum sets of standards of care for LTCF including the assessment of nutritional status by measuring body weight or albumin. Taking into account that weight tables for institutionalized persons are not ideal, the suggested OBRA criteria for the evaluation of significant weight loss are: unintentional weight loss of 5% or more in 1 month or 10% in 6 months (26).

The BMI criteria for the definition of undernutrition, differentiated for sex and age, have been based on values below the 10th percentile: less than 19 kg/m² for men and 19.4 kg/m² for women, though a BMI below the 15th percentile was correlated with an increased mortality at 6 months in seriously ill patients admitted to hospital (27). In a large cohort of healthy American non-smokers, all-cause mortality increased with a BMI lower than 23.5 kg/m² in men and 22 kg/m² in women (28). However, a recent analysis of the National Health and Nutrition Examination Survey showed that underweight, defined as a BMI under 18.5 kg/m², was associated with a significant increase in non-cancer and non-CVD mortality but not with cancer or CVD mortality (29).

Assessment tools

The Minimum Data Set (MDS) is established in some countries, such as the USA, where it has been found to be helpful in standardising screening (30). Though not specific for nutritional risk, systematic implementation of MDS section K items (oral/nutrition status) was shown in one American study to be followed by an overall reduction in the rate of nutrition decline over 6 months (31). However, there are inconsistencies between studies. MDS data were found to underestimate nutritional risk due to inaccurate documentation in one study (32, 33) and to have low specificity and sensitivity in another (32, 33). A study of 186 people (mean age 90 years) found that weight, BMI, poor oral intake, advanced cognitive decline and complaints of hunger, as collected in the MDS, were associated with the nutritional status making it possible to identify people at risk (34). Two further studies from another centre found three MDS variables to be significantly predictive of weight loss: leaving 25% or more of food at most of the meals, not being able to eat independently and receiving sedative drugs (15). The diagnosis of psychiatric or mood disorders, loss of independence in performing ADL and advanced age were predictive factors for undernutrition (15).

Other strategies have been published to identify the risk of undernutrition. Mnemonic rules like “MEALS ON WHEELS” may help to recall potentially treatable causes of undernutrition (35). However, among the available tools used to identify groups at risk in LTCF, the Mini Nutritional Assessment (MNA) is a validated instrument that is widely used by health care professionals (36, 37, 38, 39), and is currently recommended for long-term care residents by many professionals. The MNA is able to categorise the elderly into “well-nourished”, “at risk of malnutrition” and “malnourished” groups (36, 37). It is well correlated with clinical assessment, albumin, BMI, triceps skin fold, energy intake and vitamin status (40, 41). It has also been shown that the MNA predicts adverse outcomes during hospitalisation, mortality and clinical adverse events (42), as well as functional and cognitive decline and behavioral disorders among patients with Alzheimer’s disease (43).

The MNA Short Form (MNA-SF) is a useful validated screening tool. It can be used in a 2-step version combining it with the MNA (44). However, one study found no correlation between MNA-SF and clinical outcomes in hospitalized elderly after hip fracture surgery (45). An extensive overview of the MNA (46) has been published, as well as a review comparing the MNA with other nutritional screening tools (47).

Nevertheless, there is as yet no internationally agreed standardized tool for use in LTCF to systematically evaluate nutritional risk factors, nor for measuring intake, taking account of quality as well as quantity of food offered (48).

Biochemical parameters

In LTCF, the main parameters which have been used are albumin (49), cholesterol (50), haemoglobin, transferrin (26) and prealbumin (transthyretin) (51). C-reactive protein (CRP) has also been suggested (52) to assess the inflammatory process. Although the albumin has been the most widely used, it is not a good nutritional marker. The plasma albumin concentration is affected by the transcapillary escape into the interstitial fluid, as a consequence of the systemic inflammatory response syndrome. Albumin decreases in inflammatory situations as an infection, chirurgical intervention and cancer. Moreover, Albumin has a long half-life in plasma of 14-20 days. On the other hand, low plasma albumin is well established to be associated with an increase in mortality and prolonged hospital length of stay. Prealbumin is also affected by the inflammatory process; however, its half-life in plasma of about 2 days makes it more sensitive to the nutritional intake in the short time. The parameters interpretation must be done carefully analyzing the whole situation. The CRP could be an important aid to interpret all the data.

Although total lymphocyte count has been shown not to be a good nutritional marker (53), an impaired immune status, which is associated with an increase in mortality, may be improved by nutritional supplementation (54).

When interpreting the mentioned values as nutritional indicators, it has to be taken into account their specific validity.

Diet

Using standard NH documentation staff may overestimate residents’ total intake and do not reliably identify residents whose intakes fall below 75% of most meals (55). However, it has been shown that LTCF staff can be trained to keep reproducible seven-day dietetic records to estimate diet and fluid intakes of institutionalized people (56). This imeasure can be too time-consuming for routine use. A 3-day record may be a more practical alternative (57). Photographing trays before and after meals correlated well with direct observation by research staff and is more accurate than standard NH documentation (55).

Weight loss and undernutrition management in LTCF

A multidisciplinary approach is essential for the management of undernutrition in LTCF, taking into account individual needs to assess appropriate interventions. The first step is to assess the nutritional status and identify possible risk factors. Qualified dietetic input is particularly helpful for balancing the liberalisation of diets to promote palatability and quality of life while maintaining medical needs (58). The treatment of underlying diseases and associated conditions such as mood disorders, pain or infections is very important. There is also a need to pay attention to mouth hygiene and dental health and to consider withdrawing medication, especially drugs which may be causing anorexia or nausea.

General care and environment

There is a need to establish strategies to increase food intake of institutionalized elderly within available resources taking into account individual desires, needs and functional capacities of those who are assessed as undernourished or being at risk (59). Monitoring everyday emotions of patients in a rehabilitation setting positively impacted on food intake (60, 61) as did positive staff attitudes towards individualisation, importance of food and food intake (60, 61). Individuals suffering from dysphagia or dementia often require a great amount of time to maximise food intake. Environmental changes, for example using tables that allow the supervision of more than one resident at a time, can help optimise health care workers input at mealtimes (62).

A favourable atmosphere, family-style meals and a home-like environment have proved effective not only to increase energy intake and decrease the risk of undernutrition but also in maintaining quality of life, physical performance and body weight of nursing home residents (25, 63, 64, 65). Taking into account preferences and desires of residents leads to improved intake of diet and fluids. Family involvement at mealtimes in NH can be crucial where staff are unable to devote sufficient time or one-to-one supervision (66).

Counselling alone is less effective than dietary advice combined with oral supplementation in improving body weight and energy intake in short-term studies. However, the impact on clinical function and survival has been poorly studied (67). Qualified dietetic advice is important in the monitoring of individual nutritional needs and in the supervision and motivation of the health care workers who deliver nutritional care (58). Close teamwork between physicians and dieticians is crucial to optimise care (68). Management strategies in NH such as meal rounds (69) as well as projects specifically targeted to vitamin D and calcium deficiency (70) have been shown to be effective in the early identification and treatment of residents at risk.

Exercise may increase food intake in older persons (71). In a study exploring the possible interaction between exercise and nutritional supplementation in LTCF residents (72), total energy intake increased significantly in a group who received nutritional supplementation while undergoing progressive resistance exercise training. However there was no change in total energy intake in those who received either nutritional supplementation or progressive resistance exercise training alone. Continuous activity programming improved nutrition among residents with dementia in LTCF as well as decreased the need for psychotropic medication without the need for additional staff (73).

Diet

As already stated above, suboptimal food intake by residents in LTCF is a major concern and results in low intakes of energy and micronutrients. However, it is difficult to implement diets that maintain adequate micronutrient intake when the residents have a low overall intake (6). Menus should be planned to cover a wide range of energy needs and residents’ intakes should be carefully recorded to detect those at risk (26).

There are different ways to calculate caloric needs. The simplest rule is 30 to 35 Kcal/Kg/day. Harris and Benedict’s formula can be used but may overestimate needs by 10%. The protein recommendations are 1gr/Kg/day. However, in many institutionalized persons, 1.2 to 1.5 g/Kg/day are required to achieve nitrogen balance due to age-related changes in body protein distribution and amino acid metabolism (especially in women in whom the contribution of skeletal muscle mass to protein turnover is lower) (74). The until now established water requirements of 30 to 35 ml/Kg/day are being questioned nowadays (75) and further research is needed to clarify the current controversy.

Appetite should be encouraged by taking care of presentation, adequate texture and optimization of parameters such as smell, taste, colour and quantity. However, appreciating both taste and smell decline with age, flavour enhancement of food has been reported as effective in improving food intake and body weight in NH residents (76). Taking account of cultural background when designing menus can also lead to improvements in food intake (77).

Speech and language therapists (SALT) are important members of the team for assessing residents with swallowing difficulties and for training health care workers in LTCF. Video-fluoscopy may be needed to supplement clinical assessments. SALT can advise on adaptation of diet and fluid textures. Thickening agents for fluids, puréeing dietary components and using prepared products with adapted textures as substitutes for some dishes may be necessary, but such menus should be agreed with qualified dietetic help (78).

Supplementation

Given that the most consistent nutritional problem in LTCF is low intake, oral supplementation (OS) using concentrated formulas to increase total intake of calories, protein and micronutrients is a commonly used strategy. OS can increase energy intake and protein levels, improve serum albumin, retinol binding protein, hematocrit and anthropometric measures (79, 80, 81). However, most studies of OS in LTCF are of poor quality and most report problems with tolerance of the supplements (79, 80, 81). The addition of natural energy-dense ingredients to fortify meals (for example low lactose milk powder) appears to be well tolerated and to improve nutritional intake of NH residents (79, 82). There is some evidence on the efficacy of supplementation in improving outcomes in hip fracture (83), pulmonary infections (84) and pressure ulcers (85) though not for stable chronic obstructive pulmonary diseases (86). However, recent systematic reviews concluded that data was too limited to support the routine use of either OS or enteral feeding in cases of hip fracture (87), neither with the aim of preventing the development nor reducing the severity of pressure ulcers (88).

In people suffering from dementia, some studies have shown nutritional supplements to be well tolerated (89) with a reduction in morbidity and mortality (90). An increase in weight of 5% has been associated with a longer survival in special care units for Alzheimer disease (91) with reported improvements in functional and even cognitive status (92, 93). However, the recent systematic review (88) concluded that, although OS increases survival in institutionalized and/or demented persons, there is insufficient evidence of improvements in other clinical outcomes.

Many commercial formulas are available with a great range of textures and presentations. They differ by density, osmolarity, protein and lactose content and cost. The majority of them supply 1 kcal/ml. For special situations and when volume restriction is necessary, the enhancement of calorie intake might be supplied by hypercaloric formulas with 1.5 to 2.0 kcal / ml. There are also formulas prepared for special clinical situations such as kidney, liver and pulmonary disorders, malabsorption, lactase deficiency and constipation.

The general recommendation is to give 250 kcal twice daily, 2 hours after meals so as to avoid substituting the energy intake and nutrients of the normal meal.

Micronutrients and vitamins

The majority of elderly people with weight loss have one or more deficiencies in minerals or vitamins. It is possible to improve nutritional status through dietetic interventions with physiologic doses of water soluble vitamins (94). However, no consensus for specific supplementation currently exists (95), though such intervention might significantly lower homocysteine and improve serum concentrations of B group vitamins and vitamin C.

Vitamin D deficiency is common in older people in LTCF. It has been related to decline in physical performance (96) and can be effectively corrected by oral vitamin D3 supplementation with increase in serum 25(OH)D and suppression of secondary hyperparathyroidism (97, 98). Ultraviolet irradiation has also been shown to be effective in the setting of a psychogeriatric NH (97, 98). Supplementation of vitamin D improves function (99, 100, 101, 102) and the bone mineral density in older people with low vitamin D status (99, 100, 101, 102). A higher dose of vitamin D (800 IU/day) has been shown to reduce the incidence of falls in older people in LTCF, probably by improving neuromuscular function (101). Given the high incidence of falls and fractures and the severity of its consequences, systematic supplementation of 800 UI vitamin D3 because of inadequate sunlight exposure in this NH population, and 1000-1500 mg of calcium, according to dietary calcium intake, should be considered as a routine in all institutionalized older people (99, 100, 101, 102).

Many other nutrients have been studied in a variety of settings with largely inconclusive results. The following summary might help to guide clinical practice as well as future research:

• -There is no evidence for vitamin A supplementation reducing infections in institutionalized frail elderly (103).
• -Milk enriched with folic acid is an efficient and acceptable method to supplement folic acid (104) but there is a complex interaction with vitamin B12 which may produce negative as well as positive effects on anemia, cognition and the immune system (105).
• -Results on the use of oral zinc supplements or zinc plus arginine are inconsistent, though they are effective in reestablishing serum levels of zinc. There was no improvement in the immune response after vaccination in the elderly with zinc or zinc plus arginine (106), nor with zinc in healing of leg ulcers (107). Enteric formulas are often supplemented with pharmacological levels of arginine which are well tolerated by older people with normal renal function (108). Arginine supplementation had no positive effects on immune system in elderly NH residents with pressure ulcers (108) but a small study has shown improved rate of healing of pressure ulcers when arginine was given with vitamin C and zinc supplements (109). However, the capacity of nutritional supplementation to improve immune function, lymphocyte or interleukin 2 production and proliferation remains to be confirmed (110).
• -Iodine and selenium deficits have an influence on the regulation of thyroid hormones (111).
• -Short term supplementation of antioxidant vitamins and trace elements in the elderly might improve immune function (112, 113) producing an increase in IL-1 levels (112, 113).
• -The role of antioxidants vitamins and specially carotenoids on cancer promotion is still in debate (114, 115).

Tube Feeding

When a person cannot meet their dietary requirements orally, tube feeding should be considered. The only absolute contraindications are intestinal obstruction and short bowel syndrome. Access to the gastrointestinal system is via naso-gastric, naso-intestinal, percutaneous gastrostomy or jejunostomy. Percutaneous endoscopic gastrostomy (PEG) is the preferred method when long-term feeding is needed. Usually, preparations used are prepared formulas that cover recommended amounts of macro- and micronutrients as well as water. Most formulas have 1 kcal/ml.

Poor nutritional status is not the only criterion to take into account when considering the introduction of tube feeding. A CGA should be performed for all possible candidates for tube feeding. General benefits should be evaluated taking into account the needs and the desires of the affected person and his/her family. Many institutionalized individuals have severe and progressive conditions, especially neurodegenerative disorders with severe disability, in which no benefit on survival has been demonstrated by tube feeding. Indeed, there is insufficient evidence of overall benefit from randomised controlled trials (RCT) in malnourished older people generally and in the specific instances of hip fracture and pressure ulcer healing (88). Nor has benefit on quality of life been consistently shown. There are no RCTs on the use of enteral nutrition in demented persons (88). The decision to introduce tube feeding should be made after a comprehensive evaluation taking into consideration all clinical, prognostic and ethical aspects. There is an extensive literature on the ethical, legal, cultural and religious influences on decisions regarding tube feeding which is beyond the scope of this paper.

Drugs

Orexigenics might be considered in people with persistent anorexia (116), although its use is controverse. Dronabinol and megestrol have been shown in pilot studies to enhance weight gain in cases of geriatric cachexia and to improve quality of life (117, 118, 119). However, their efficacy seems to be low. Moreover, orexigenics have been reported as having potentially serious side effects such as loss of lean body mass, slower progress in rehabilitation and other corticosteroid-related side-effects, particularly megesterol (120). Therefore, a good selection of cases to treat is necessary.

Advance care planning

Advance directives may be especially important in the context of enteral nutrition. Advanced care planning should be routinely encouraged in the relationship with patients, informing them about the complexity of enteral feeding (121). The documentation of advance directives is now regulated in several countries.

Practical and progressive procedures to be used in LTCF

Figures 1, 2 and 3 show successive steps for a progressive assessment in LTCF. 3 steps or levels of assessment and intervention are shown. These steps are not necessarily consistent with other protocols established in other countries. This proposal is based on the actual situation of many residential homes in order to address the limited availability of diagnostic procedures. The three level schema presented has to be taken as a global process and the time given to pass from level to level has to be adapted in each case.

Figure 1.

First level: systematic assessment of each person admitted to a LTCF

Figure 2.

Second Level: global assessment of risk factors and intervention begin

Figure 3.

Third level: further assessment and treatment

First level: systematic assessment of every person on admission to a LTCF

Every person admitted to a LTCF should be assessed with a simple dietetic questionnaire. Information obtained on a 3-day food intake assessment will lead to the further steps. If the intake is equal to or greater than 75% of the administered food, considering that the administered food is adequate to the patient needs providing 30kcal/kg, individuals should be weighed monthly for the first 3 months. If the weight is stable and there are no clinical changes, weight should be monitored every 3 months as surveillance of nutritional status. If weight loss occurs, once ruled out that weight loss is due to changes in total body water, the next step is to perform the second evaluation level. If the intake is below 75% for at least three consecutive days during the initial assessment, the person is at risk and the second evaluation level should be performed.

It has to be taken into account that weight changes may be also caused by changes in the body water amount and mask the actual weight, which may be lower or higher. Thus, weight loss could lead to the false diagnostic of nutritional problem, while it could be a favourable sign for instance of oedema reduction. Physical examination, medical history and the dietetic questionnaire can help us to interpret properly the data.

Second Level: global assessment of risk factors and intervention begin

Risk factors for nutritional disorders and their associated aspects should be identified. The nutrition-related care process should be carefully examined, e.g. if the patient is being provided adequate feeding assistance. The evaluation is completed with the weight record or BMI. Height can alternatively be estimated from knee height (122), since his imprecision has little impact on BMI calculation. Evaluation tools are helpful to precise the nutritional status. Tools such as the MNA should be used, which would help to classify the person in risk levels and evaluate the severity. Additionally in depth detection of potentially correctable risk factors might be needed.

If there is an unintentional weight loss of up to 5% in one month or 10% in 6 months or the BMI is 19 to 23 kg/m², treatment should be started. These BMI cut offs should be seen with caution, since there are still too few data to choose one discrete value. In fact, 19 could be too low and patients close to this value could be already undernourished or in severe risk of undernutrition. The lower the BMI, the higher the risk. Intervention should be multidisciplinary and address the different risk factors. The suitability of the environment and that of the diet should be reviewed, as well as the consistency, texture, flavour and the presentation of the food. It might be appropriate to add products with formulas that replace normal meals with an adapted presentation such as texture modified food. Reassessment of associated problems: chronic diseases, drugs and treatment of acute diseases should be conducted. Mouth hygiene and dentition should be assessed. Drugs like megestrol might be tried.

Third level: further assessment and treatment

This third level should be started when the evaluated person has signs of undernutrition. People with weight loss of 5% in one month or 10% in the last 6 months or a BMI less than 19 kg/m² and insufficient oral intake need a more complete evaluation with biochemical markers. People with weight loss less than these values but who do not respond to second level interventions should be included in this third level. When a nutritional treatment is introduced with a specific aim, biochemical parameters such as albumin, prealbumin and CRP might be helpful to monitor whether the intervention is beneficial. Oral supplementation of 500 kcal/day of a prepared formula taken 2 hours after main meals should be given for 7 days, if possible. A re-evaluation of the clinical situation after this period of time should take place with transthyretin, if available, since albumin has a long half-life and would depict long-term effects but not fast changes. Daily intake should be monitored continuously, if possible, considering that oral supplementation may lead to a reduction in nutrient intake form other sources. If the improvement continues, oral supplementation should be continued. Tube feeding might be necessary to assure sufficient intake of macro- and micronutrients and water. If tube feeding is to be considered, special care must be taken in evaluating the characteristics and desires of the individual, aims of tube feeding and baseline pathologies. Moreover, an assessment of the nutrition-related care process should be done carefully. If tube feeding is expected to last more than one month, the placement of a PEG tube should be considered (figure 3). Unfortunately, the lack of evidence hinders to specify guidelines on this topic.

Summarizing, nutritional care in LTCFs has to be person-centred and therefore based on a holistic assessment taking into account the needs, desires and rights of the individual together with the results of the comprehensive geriatric assessment (CGA) (58).

Acknowledgements: We would like to acknowledge Vegenat SA for the financial support. Vegenat did not interfere in the results. Furthermore, we would like to thank José Manuel Ribera Casado and Francisco Guillén Lera for initiating the Task Force on Nutrition and Ageing of the IAGG European Region.