Response # 1 to Candace
Nutrition and Hydration
The assessment of functional status in the aging population is critical. There are several conditions that may cause a decline in an elderly patients ability to perform task that are necessary for independent living, these include:
· Normal aging process,
· Acute illness,
· Worsening chronic illness
· Hospitalization or environmental changes (Graf, 2013).
The functional assessment can provide objective data to assist providers in determining the level of care needs for the patient and can also help determine a patients baseline capabilities, to focus on early recognition of changes (Graf, 2013).
My patient, E.S. is a 76 year old female with a history of progressing Alzheimer’s disease. Her family noticed a recent significant change in her cognition and her functional capabilities. My preceptor and I decided to utilize the Lawton Instrumental Activities of Daily Living Scale (IADL). The Lawton IADL scale is an assessment tool to assess E. S. for her ability to stay in the assisted living facility where I am doing clinical. The instrument is a series of questions or observations by the provider and/or caregivers that assign points for each answer and a total score is given with >6 being more capable of independent living and <6 being less capable (Graf, 2013).
These areas are all covered:
· Ability to use the telephone (E.S. scored 1 for answers phone but does not dial)
· Shopping (E.S. scored a 0 for needing to be accompanied on shopping trips)
· Food preparation (E.S. scored a 0 for needing to have meals prepared and served)
· Housekeeping (E.S. scored a 1 for performing light tasks and needing help with acceptable levels of cleanliness)
· Laundry (E.S. scored a 0 as all laundry must be done for her)
· Mode of Transportation (E. S. scored a 0 for having limited travel and requiring assistance)
· Responsibility of Medications (E.S. scored a 0 for having to have her medication dispensed to her by someone else)
· Ability to handle finances (E.S. scored a 0 for being incapable of managing money) (Graf, 2013).
Her total score was a 2 meaning she is incapable of living independently and meeting her own nutritional and hydration needs.
Advanced Alzheimer’s disease (AD) creates difficulty with maintaining safe independent functioning as the patients become reliant on caregivers for bathing, toileting, and feeding (Kamikado Pivi, Ferreira Bertolucci, & Schultz, 2012). Nutrition and hydration become a particular concern, as AD is associated with feeding problems, difficulty swallowing, failing to swallow, choking concerns, and resistance to hand feeding (Kamikado Pivi, et al., 2012). Patients with AD are more prone to weight loss issues and malnutrition can result in alteration of general health status, increased rates of infection, and a faster loss of independence (Kamikado Pivi, et al., 2012). E.S. is on a regular diet and wears dentures, though the staff and family brought it to our attention that she has not been wearing them as frequently as she has misplaced them several times recently. Although she has not had a weight loss at this time, this alone places her at risk for weight loss and malnutrition.
We asked for speech therapy to do an evaluation on her to see if she is able to tolerate a regular diet with and without her dentures in place. Speech therapy also will evaluate her for dysphagia and aspiration risk. She currently can feed herself, just unable to prepare the meals on her own. She lives in our assisted living facility where her meals are prepared for her and served to her daily. Re-evaluation of her Lawton IADL assessment may be required on a regular basis to pick up functional decline that may require further intervention. We placed her on the daily weight list and asked the dietician to review her as well. A nutritional assessment is important as inadequate micronutrient intake is common in the elderly (Elsawy & Higgins, 2011). Vitamins A, C, D, and B12, calcium, iron, and zinc can be deficient in the elderly, even without the presence of chronic conditions (Elsawy & Higgins, 2011). As of now, her lab values for potential nutritional deficits are within normal limits, although we recheck these labs every 3 months. E.S. is a DNR and has requested no parenteral or enteral nutrition, thus those options would not be an option for nutritional supplementation in the future. For her hydration needs, she will need to be offered liquids on a regular basis throughout the day and the staff, as well as her family, are aware of this. E.S. is also on Namenda for treatment of her AD and the related side effects are usually gastrointestinal, therefore it is vital to not any side effect from her medication and whether it may impair her food intake (Kamikado Pivi, et al., 2012). Other issues to consider that might be related to nutrition and hydration are depression, elimination of restrictive diets, consideration of individual food preferences, and reduction of disruptive stimuli (Flaherty & Resnick, 2014).
Elsawy, B., & Higgins, K. E. (2011). The geriatric assessment. American Family Physician, 83(1), 48-56.
Flaherty, E., & Resnick, B. (Eds.). (2014). Geriatric nursing review syllabus: A core curriculum in advanced practice geriatric nursing (4th ed.). New York, NY: American Geriatrics Society
Graf, C. (2013). The Lawton Instrumental Activities of Daily Living (IADL) Scale. The Gerontological Society of America, 23. Retrieved January 10, 2017 from http://micmrc.org/system/files/IADL.pdf
Kamikado Pivi, G. A., Ferreira Bertolucci, P. H., & Schultz, R. R. (2012). Nutrition in sever dementia.Current Gerontology and Geriatrics Research, 2012, article ID 983056. doi: 10.1155/202/983056
Response # 2 to Ebony
Nutrition and Hydration
The Lawton Instrumental Activities of daily living Scale (IADLs) scale assesses an individual’s ability to care for themselves. Katz has an activities of daily living (ADL) scale that is used to measures and individual’s ability to care for themselves as well. Each scale measures something different. Such as the ADL scale consisting of activities that involves hygiene. The ADL scale measures someone’s ability of being able bath, dress themselves, toilet themselves, move around with ease, remain continent and feed themselves (Graf, 2008). IADLs measure the person’s ability to answer the phone, shop, prepare food, perform housekeeping chores, do laundry, use transportation, handle their medications and handle their finances (Graf, 2008). ADLs and IADLs affects a person’s nutritional and hydration status. It can either cause the individual to have an over or under-nutritional status (Flaherty & Resnick, 2014).
The patient that the IADL tool was used for was a sixty-eight-year-old male. On the IADLs scale for ability to use the phone he scored a 1, shopping 0, food preparation 0, housekeeping 1, laundry 0, mode of transportation 0, responsibility for own medication 1, ability to handle finances 0 (Lawton, M.P. & Brody, E.M., 2017). Per the scale, he cannot perform most activities alone requiring the need for help which allows him to qualify for assistance from an outside source. His nutritional and hydration statuses can be affected by the scale, which is why he is now receiving food from meals on wheels. The reason for this is because he is unable to prepare his food and has right sided weakness from a previous cerebral vascular accident (CVA). He is on a regular diet with thin liquids. With his history of diabetes and hypertension, his diet is limited on the amount of sodium and sugar he is permitted to ingest. He does have primary hyperparathyroidism which causes him to have excessive thirst. This puts him at risk for over hydration and he does have bilateral lower extremity edema.
Some strategies to help improve his nutritional and hydration status is education. He lives home alone, which warrants the need for home health or facility placement, and his daughters must be made aware of this. He is currently on the meals on wheels program, which supplies his nutritional needs. As far as preventing over hydration, his drinks can be measured by having him drink out of one specific container so that he will not over drink himself. His medication is set up in a pill container for each day and the time, which makes it easier for him to keep track of his medication dosages and frequencies.
Graf. C.(2008).The Lawton Instrument of Daily Living Scale. Retrieved from https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Clinician%20Resources/Geriatric%20Resources/Advanced%20Illness%20and%20Planning/Lawton_Activities_Daily_living_Scale.pdf..
Lawton, M.P. & Brody, E.M.(2017).Instrumental Activities of Daily Living. Retrieved from http://www.strokecenter.org/wp-content/uploads/2011/08/lawton_IADL_Scale.pdf.
Flaherty, E., & Resnick, B. (Eds.). (2014). Geriatric nursing review syllabus: A core curriculum in advanced practice geriatric nursing (4th ed.). New York, NY: American Geriatrics Society.
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