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Title: Nutrition/Disease Prevention - Nutrition Screening Initiative from the AAFP Nutrition checklist designed to alert individuals, family members, and phsicians to conditions that may lead to malnutrition, particularly in the aged. (March 1, 1998)
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Dealing_with_a_Crying_Infant Information and advice regarding what to do with a crying baby, including why newborns cry, what's normal, and tips on how to quiet a them.
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 Home Page > News & Publications > Journals > American Family Physician® > Vol. 57/No. 5 (March 1, 1998)  Advanced Search          Articles | Departments | Patient Information Editorals Nutrition and Health BRUCE BAGLEY, M.D. Albany Medical College, Albany, New York Family physicians, managed care organizations and health planners are becoming increasingly aware of the value of good nutrition in the prevention and treatment of disease. Our focus as a health care system will shift from individual disease-oriented office visits to concern for maintaining and improving the health of our citizens. Nutrition education, nutrition screening for the elderly and the therapeutic use of medical foods will become more important to practicing physicians and family practice educators. The American Academy of Family Physicians, in partnership with the American Dietetic Association and the National Council on Aging, has promoted the Nutrition Screening Initiative (NSI). The NSI has succeeded in raising the level of awareness of physicians, politicians and the public to the importance of nutrition in the elderly. The NSI commissioned a study1 by the Barents Group to estimate the cost savings that could be achieved if our elderly citizens were systematically screened for nutritional deficiency. The study documented compelling evidence that older patients who are admitted to the hospital in a compromised nutritional state had longer lengths of stay and increased rates of complications than well-nourished patients. Moreover, the investigators estimated that the total cost of poor nutrition for Medicare over the next six years would be $1.3 billion, primarily in increased hospital costs. All too often, older patients are admitted for medical or surgical diagnoses and placed on intravenous fluids for days with no nutritional support. The great majority of these patients have a normal bowel that could be used for enteral nutrition from the time of admission. Family physicians must become more aware of the nutritional needs of our elderly patients. Reviews on implementing enteral nutrition are available.2 We encourage family physicians to improve their knowledge and skills in enteral nutrition. The NSI has developed a simple screening tool that may be self administered or graded by any health care professional or family member (see Table). We encourage all family physicians to screen their older patients using this simple tool and recommend interventions when necessary. Community efforts that aid in meal procurement or preparation, coupled with nutritional supplements and enteral nutrition when indicated, will go a long way to improving the health and well-being of our senior citizens. The cost savings to our ailing Medicare system are clearly documented in the Barents study.1 For more information about the Nutrition Screening Initiative, contact the NSI, 1010 Wisconsin Ave., Ste. 800, Washington, D.C. 20007-3603; telephone: 202-625-1662. The table was reprinted with permission from the Nutrition Screening Initiative, a project of the American Academy of Family Physicians, the American Dietetic Association and the National Council on Aging, Inc., and sponsored by Ross Products Division of Abbott Laboratories. REFERENCES The clinical and cost-effectiveness of medical nutrition therapies: evidence and estimates of potential medicare savings from the use of selected nutrition intervention. Summary report prepared for the Nutrition Screening Initiative. Washington, D.C., Barents Group of KPMG Peat Marwick LLP, June 1996. Rodney DP, Gaskins SE. Optimizing enteral nutrition. Am Fam Physician 1996;53:2535-42. Dr. Bagley is clinical associate professor in family practice at Albany Medical College. He is a member of the Board of Directors of the American Academy of Family Physicians and chair of the AAFP Commission on Health Care Services. Determine Your Nutritional Health The warning signs of poor nutritional health are often overlooked. Use this checklist to find out if you or someone you know is at nutritional risk. Read the statements below. Circle the number in the yes column for those that apply to you or someone you know. For each yes answer, score the number in the box. Total your nutritional score. YES I have an illness or condition that made me change the kind and /or amount of food I eat. 2 I eat fewer than two meals per day. 3 I eat few fruits or vegetables, or milk products. 2 I have three or more drinks of beer, liquor or wine almost every day. 2 I have tooth or mouth problems that make it hard for me to eat. 2 I don't always have enough money to buy the food I need. 4 I eat alone most of the time. 1 I take three or more different prescribed or over-the-counter drugs a day. 1 Without wanting to, I have lost or gained 10 pounds in the last six months. 2 I am not always physically able to shop, cook and/or feed myself. 2 TOTAL Total your nutritional score. If it's-- 0-2 Good! Recheck your nutritional score in six months. 3-5 You are at moderate nutritional risk. See what can be done to improve your eating habits and lifestyle. Your office on aging, senior nutrition program, senior citizens center or health department can help. Recheck your nutritional score in three months. 6 or more You are at high nutritional risk. Bring this checklist the next time you see your doctor, dietitian or other qualified health or social service professional. Talk with them about any problems you may have. Ask for help to improve your nutritional health. Remember that warning signs suggest risk, but do not represent diagnosis of any condition. The Nutrition Checklist is based on the warning signs described below. Use the word DETERMINE to remind you of the warning signs. Disease Any disease, illness or chronic condition that causes you to change the way you eat, or makes it hard for you to eat, puts your nutritional health at risk. Four out of five s have chronic diseases that are affected by diet. Confusion or memory loss that keeps getting worse is estimated to affect one out of five or more of older s. This can make it hard to remember what, when or if you've eaten. Feeling sad or depressed, which happens to about one in eight older s, can cause big changes in appetite, digestion, energy level, weight and well-being. Eating Poorly Eating too little and eating too much both lead to poor health. Eating the same foods day after day or not eating fruit, vegetables and milk products daily will also cause poor nutritional health. One in five s skips meals daily. Only 13 percent of s eat the minimum amount of fruits and vegetables needed. One in four older s drinks too much alcohol. Many health problems become worse if you drink more than one or two alcoholic beverages per day. Tooth Loss/Mouth Pain A healthy mouth, teeth and gums are needed to eat. Missing, loose or rotten teeth or dentures which don't fit well or cause mouth sores make it hard to eat. Economic Hardship As many as 40 percent of older Americans have incomes of less than $6,000 per year. Having less--or choosing to spend less--than $25 to $30 per week for food makes it very hard to get the foods you need to stay healthy. Reduced Social Contact One-third of all older people live alone. Being with people daily has a positive effect on morale, well-being and eating. Multiple Medicines Many older Americans must take medicines for health problems. Almost one half of older Americans take multiple medicines daily. Growing old may change the way we respond to drugs. The more medicines you take, the greater the chance for side effects such as increased or decreased appetite, change in taste, constipation, weakness, drowsiness, diarrhea, nausea and others. Vitamins or minerals when taken in large doses act like drugs and can cause harm. Alert your doctor to everything you take. Involuntary Weight Loss/Gain Losing or gaining a lot of weight when you are not trying to do so is an important warning sign that must not be ignored. Being overweight or underweight also increases your chance of poor health. Needs Assistance in Self Care Although most older people are able to eat, one of every five has trouble walking, shopping, buying and cooking food, especially as they get older. Elder Years Above Age 80 Most older people lead full and productive lives. But as age increases, risk of frailty and health problems increase. Checking you nutritional health regularly makes good sense. Ten Commandments for the Care of Terminally Ill Patients JAMES R. WHITTEN, M.D. University of Missouri at Kansas City One criticism of physicians is our difficulty in responding to the emotional circumstances of patients who are terminally ill. Working as a consultation-liaison psychiatrist for many years, I have had an opportunity to assist physicians from all specialities in attending their patients who are terminally ill. Even the most thoughtful physicians struggle with issues that arise during their care of dying patients. I am not referring here to euthanasia or assisted suicide of the terminally ill,1 but rather the entire emotional climate that surrounds this final process when everything that can be done medically is being done. About a decade ago, I read an article titled "The Ten Commandments of Medical Etiquette for Psychiatrists"2 that helped me focus on my responsibilities as a consulting psychiatrist. Also, I was aware of another article that made a similar contribution to internal medicine.3 I am offering a similar outline for the emotional care of the patient during the terminal stages of illness. Although much more could be said about each area listed below, this outline is meant only to form the foundation for the individual variations that each case will demand: I. Be a "straight shooter." For years, I have observed that patients and their families insist that the physician be a "straight shooter." This means to me that the physician should use the truth when it is requested and in the amount it is requested to assure the optimal sense of well-being under the circumstances. It may not cure or bring happiness, but being truthful indicates to the patient that the physician can be counted on to accurately describe and negotiate the difficult times ahead. Listening to the patient or their families will, in large part, indicate when they need plans for negotiation of difficult times. Remember, ethnicity and culture may make a difference,4 so ask patients if they wish to receive the information and make decisions or if they prefer the family to handle such matters. II. Be empathetic. The quality of understanding how another person feels and to be in "tune" with your patients is extremely important and forms the basis for all contact with the patient and the family. Temporary or partial identification with your patient will allow you to understand what he or she is feeling. Patients feel better when you show them that you are aware of their emotional experiences. III. Ask about consultations. Patients and their families should be asked about the use of additional subspecialty consultations. This topic should be raised by the attending physician at any time during the terminal stages, but it is especially important in the final stages. At this time, the patient and the family are most vulnerable and dependent on the attending physician and may be reluctant to ask for additional professional help because they do not wish to offend. Introduce the idea of medical, psychiatric, surgical or other subspecialty consultation early. Your willingness to assemble a team of caregivers will not be perceived as an indication of inadequacy, and you will only gain respect from the patient and the family. IV. Do not abandon. One of the most distressing situations for the patient or the family is for the primary physician to "sign off" of the case, leaving the care to an unfamiliar physician, such as a hospice or a nursing home physician. Even if the primary care physician is not directly involved with the treatment, he or she should spend time with the patient and the family. It is especially important to be there during the bad times and be aware of the family's needs, because this is indeed a family affair.5 V. Maintain a regular routine of hospital calls. Just as it is important not to abandon the patient to a consultant, it is equally important to maintain regular visits to the patient who is terminally ill. The patient and the family are acutely aware of the frequency and the duration of visits. Physicians have a tendency to change their schedule and shorten their visits when patients enter the final stages of illness. One does not have to be a psychiatrist to be aware of the impact of this behavior on the patient and the family. This distancing tactic is well described.6 Keeping up the frequency and duration of the visits will increase your understanding of the patient, the family and yourself. VI. Obtain support from colleagues and family. There are many causes of burnout in those who care for the terminally ill.7 Also, it goes without saying that physicians frequently need support or possibly personal involvement with a mental health professional. However, to avoid the peaks and valleys of emotional response, it is acceptable to seek support from your colleagues and hospital staff by discussing patients' feeling and situations. Once a discussion is started, many colleagues and staff may join in the exchange of information and feelings. These discussions often take place at the nurses' station in the intensive care unit or the coronary care unit. The physicians' lounge and the surgical dressing room are other areas where discussions can be held. Maybe the best of all situations is to discuss your feelings about a certain patient with a spouse or a close family member. The practice of medicine is also a family affair. VII. Communicate with the patient's family. Family members can be a great source of information, supportive advocates and decision makers for the patients. But, they can also oppose the wishes of the patient and the treatment team. Like the patient, they reveal a wide range of responses to the terminal illness of a family member that requires understanding at critical junctures.8 Appointing family members with whom to communicate regularly can be helpful. When talking with the family, remember to use as little medical jargon as possible and expect that, as with the patient, there will be anger, distrust, fear of the medical surroundings, depression, frustration, guilt and a great deal of anxiety.9 VIII. Preserve the humanness of the patient. It is essential to maintain the idea that "quality of life" is an important issue even for patients in whom a cure is no longer expected. This is true even for patients who are close to death.10 Human values remain important.11 Again, the physician's response can be one of distancing to preserve the "powerful healer" image. Also, physicians can hide behind the machines, charts, bottles, tubes and mechanical apparatus that overwhelm the family and dehumanize the patient. While all of these machines are necessary, we should remind ourselves that a cure is not the objective, and our goal is to help the patient remain a human being during the process of dying. IX. Be concerned about where the patient dies. We assume that if the patient is in the hospital or in a hospice that necessary care will be available. However, some patients and their families will want to spend this time in other places, such as the home. Then, the availability of urgent care, financial help for the patient from local charities, pain control and administration of adequate amounts of medication become real issues. Physicians must be aware of what support is available in their communities. X. Preserve hope. I leave this point to last because the preservation of hope should be the last to leave. When physicians think, "No matter what I do, she (the patient) is going to die," they may be unable to help their patients preserve hope. Most patients, even the most realistic, leave some room for the possibility of a cure. It is this glimpse of hope that sustains them. Here, as so often, humanity depends on honesty. Do not use false evaluations in the response to the inevitable question of "How long do I have?" Usually what the patient wants is someone to listen to them in an objective manner. Share the hope and do not paint the picture as completely hopeless or emotionally abandon the patient with words such as "always" or "never."9 We should be aware of our own feelings such as guilt, helplessness and inadequacy. We do not need to validate our competency as physicians by the survival of every patient. When hope is preserved, the patient will show much confidence and appreciation.12 REFERENCES Block SD, Billings JA. Patient requests for euthanasia and assisted suicide in terminal illness. The role of the psychiatrist. Psychosomatics 1995;36: 445-57. Pasnau RO. Ten commandments of medical etiquette for psychiatrists. Psychosomatics 1985;26: 128-32. Goldman L, Lee T, Rudd P. Ten commandments for effective consultation. Arch Intern Med 1983;143: 1753-5. Blackhall LJ, Murphy ST, Frank G, Michel V, Azen S. Ethnicity and attitudes toward patient autonomy. JAMA 1995;274: 820-5. Leonard KM, Enzle SS, McTavish J, Cumming CE, Cumming DC. Prolonged cancer death. A family affair. Cancer Nurs 1995;18:222-7. Maguire P. Barriers to psychological care of the dying. Br Med J (Clin Res Ed) 1985;291:1711-3. Martin CA, Julian RA. Causes of stress and burnout in physicians caring for the chronically and terminally ill. Hospice J 1987;3:121-46. Rothchild E. Family dynamics in end-of-life treatment decisions. Gen Hosp Psychiatry 1994;16:251-8. Strain JJ, Grossman S, eds. Psychological care of the medically ill; a primer in liaison. New York: Appleton-Century-Crofts, 1975. Fowlie M, Berkeley J. Quality of life: a review of the literature. Fam Pract 1987;4:226-34. Kohn J. Human values in caring for cancer patients. Can Med Assoc J 1984;131:237-9. Kubler-Ross E. On death and dying. New York, MacMillan, 1969:138-80. * Dr. Whitten is assistant professor of psychiatry at the University of Missouri at Kansas City and senior attending psychiatrist at Western Missouri Mental Health Center in Kansas City. He is also director of the Consultation-Liaison service at Truman Medical Center, Kansas City. March 1, 1998 Contents | Subscribe | Search | AFP Home Page Article Tools Email this page  Printer-friendly AFP CME Quiz Search AFP AFP Advanced Search
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Nutrition | checklist | designed | to | alert | individuals, | family | members, | and | phsicians | to | conditions | that | may | lead | to | malnutrition, | particularly | in | the | aged. | (March | 1, | 1998) |
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