Nutrition support teams: Institution, evolution, and innovation.

The historical institution, evolution, and innovations of nutrition support teams (NSTs) over the past six decades are presented. Focused aspects of the transition to transdisciplinary and patient-centered care, NST membership, leadership, and the future of NSTs are further discussed. NSTs were instituted to address the need for the safe implementation and management of parenteral nutrition, developed in the late 1960s, which requires the expertise of individuals working collaboratively in a multidisciplinary fashion. In 1976, the American Society for Parenteral and Enteral Nutrition (ASPEN) was established using the multidisciplinary model. In 1983, the United States established the inpatient prospective payment system with associated diagnosis-related groupings, which altered the provision of nutrition support in hospitals with funded NSTs. The number of funded NSTs has waxed and waned since; yet hospitals and healthcare have adapted, as additional education and experience grew, primarily through ASPEN's efforts. Nutrition support was not administered in some instances by the "core of four" (physician, nurse, dietitian, pharmacist). The functions may be carried out by a member of the core of four not associated with the parent discipline, in accordance with licensure/privileging. This cross-functioning has evolved into the adaptation of the concept of transdisciplinarity, emphasizing function over form, supported and enhanced by "top-of-license" practice. In some institutions, nutrition support has been incorporated into other healthcare teams. Future innovations will assist NSTs in providing the right nutrition support for the right patient in the right way at the right time, recognizing that nutrition care is a human right.

Department of Veterans Affairs Geriatric Research, Education and Clinical Centers: translating aging research into clinical geriatrics.

Department of Veterans Affairs (VA) Geriatric Research, Education and Clinical Centers (GRECCs) originated in 1975 in response to the rapidly aging veteran population. Since its inception, the GRECC program has made major contributions to the advancement of aging research, geriatric training, and clinical care within and outside the VA. GRECCs were created to conduct translational research to enhance the clinical care of future aging generations. GRECC training programs also provide leadership in educating healthcare providers about the special needs of older persons. GRECC programs are also instrumental in establishing robust clinical geriatric and aging research programs at their affiliated university schools of medicine. This report identifies how the GRECC program has successfully adapted to changes that have occurred in VA since 1994, when the program's influence on U.S. geriatrics was last reported, focusing on its effect on advancing clinical geriatrics in the last 10 years. This evidence supports the conclusion that, after more than 30 years, the GRECC program remains a vibrant "jewel in the crown of the VA" and is poised to make contributions to aging research and clinical geriatrics well into the future.

Education partnerships between GRECCs and other VA organizations, Non-VA governmental agencies, academic medical centers, and centers of excellence.

Gerontology and geriatrics are interdisciplinary professions. The quality of the care and services provided by the members of these professions depends upon the strength and integrity of the partnerships between the professionals working together. This article summarizes the partnerships created by the Department of Veterans Affairs Geriatric Research, Education, and Clinical Centers. This myriad of partners has formed the basis of successful programming to improve clinical care, to expand research projects, and most specifically, to produce educational opportunities in geriatrics and gerontology that have the potential to improve the quality of life for older Veterans.

The Arkansas aging initiative: an innovative approach for addressing the health of older rural Arkansans.

The Donald W. Reynolds Institute on Aging at the University of Arkansas for Medical Sciences in Little Rock is addressing one of the most pressing policy issues facing the United States: how to care for the burgeoning number of older adults. In 2001, the Institute created the Arkansas Aging Initiative, which established seven satellite centers on aging across the state using $1.3 to $2 million dollars annually from the state's portion of the Master Tobacco Settlement. These centers on aging assist the state's population of older adults, many of whom reside in rural areas, live in poverty, and suffer from poor health. The centers provide multiple avenues of education for the community, health care providers, families, and caregivers. The Arkansas Aging Initiative, in partnership with local hospitals, also makes geriatric primary and specialty care more accessible through senior health clinics established across rural Arkansas. In 2005, older adults made more than 36,000 visits to these clinics. All sites have attracted at least one physician who holds a Certificate of Added Qualifications in geriatrics and one advanced practice nurse. Other team members include geriatric medical social workers, pharmacists, nutritionists, and neuropsychologists. This initiative also addresses other policy issues, including engaging communities in building partnerships and programs crucial to maximizing their limited resources and identifying opportunities to change reimbursement mechanisms for care provided to the growing number of older adults. We believe this type of program has the potential to create a novel paradigm for nationwide implementation.

An overview of tube feeding: from ancient times to the future.

The history of enteral feeding goes back about 3,500 years to the ancient Greeks and Egyptians, who infused nutrient solutions into the rectum to treat various bowel disorders. Over the centuries, experimentation and research have contributed to a greater understanding of nutrient requirements; methods to more accurately access the gastrointestinal tract; development of new materials to use in equipment, tubes, and containers; and the digestion, absorption, and use of macro- and micronutrients. It is notable that while advances were made in one area, progress was being made in another. For example, while enteral access and feeding techniques were being developed, essential amino acids were identified. When new information came together, rapid changes opened up the applications for enteral feeding in new directions, sometimes in unexpected ways such as diets designed for the space program, leading to the use of elemental diets as a therapeutic modality.

Tube feeding patients with dementia.

As the population ages, the incidence of dementia increases. All types of dementia, whether they are reversible or irreversible, lead to loss of intellectual function and judgment, memory impairment, and personality changes. The skills to feed oneself, use eating utensils, and consume items recognized as food, thereby maintaining nutrition status, may be lost as dementia progresses. Reports indicate that nutrition status may be maintained when patients are hand fed, but this is labor intensive and therefore expensive. Feeding via a percutaneous endoscopic gastrostomy tube is often chosen as an acceptable alternative. Research indicates that there is little benefit in this population when aggressive nutrition support is instituted. Providing tube feeding to patients with dementia does not necessarily extend life, increase weight, or reduce the incidence of pressure ulcers or aspiration. There are many legal and ethical issues involved in the decision to place a feeding tube in demented patients. The primary issue in patients with dementia may be autonomy and the right of an individual to decide whether or not a tube should be placed at all. Legally, there is clear precedent that the courts see the insertion of a feeding tube as extraordinary care that the patient has the right to refuse. However, much of case law is derived from cases of patients who were in a persistent vegetative state. Advance directives help to determine what the patient would want for himself. Considering all the options before the patient can no longer make decisions is the most desirable course.

Dietary management for older subjects with obesity.

In recent years, obesity has been recognized as a form of malnutrition in older adults and a continuing risk factor for serious health problems. Weight reduction in older adults is not as reliable a recommendation as it is for younger adults; a decreased body mass index (BMI) seems to be associated with a higher incidence of stroke, and a normal or slightly elevated BMI has been linked to greater reserve capacity. Weight loss in older adults requires strategies that consider health status, functional ability, and rational targets. Strategies may include behavior modification, dietary alterations, exercise or physical activity, and reasonable goals that do not put the individual at nutritional risk. Studies that examine different approaches to weight reduction rarely include older subjects, so it is difficult to make judgments about various interventions (surgery, exercise, drugs, or diet) and their efficacy in this population. Fad diets may be lacking in essential nutrients and may prove to be risky for elderly people. Weight loss programs for older adults should focus on maintaining adequate intake of essential nutrients while reducing calories by controlling dietary fat intake.

Micronutrient requirements in older women.

The nutritional requirements of older women is an area of great interest because the extended life expectancy leads to an increase in women living into their 80s, 90s, and longer. The recommended dietary allowances (RDAs) and dietary reference intakes (DRIs) are not specific for women living to advanced ages, and little research has been conducted specifically on the micronutrient needs of elderly women. Older adults are at greater risk for nutritional deficiencies than are younger adults due to physiologic changes associated with aging, acute and chronic illnesses, prescription and over-the-counter medications, financial and social status, and functional decline. Among the significant age-associated changes in nutrient requirements, the need for energy decreases and the requirements for protein increase with age. Among the micronutrients, the significant ones that may be associated with deficiencies in elderly women include vitamin B-12, vitamin A, vitamin C, vitamin D, calcium, iron, zinc, and other trace minerals. In old and very old women, these are micronutrients of interest but there is a great need for research to determine appropriate recommendations. The importance of these selected nutrients and the reasons for the likelihood of deficiency are discussed briefly. However, there is little specific information regarding micronutrient requirements for elderly women. One reason for this is the difficulty in conducting reliable and valid studies due to the heterogeneity of older adults and their unique rate of aging associated with their health status, limited income, disability, and living situation.

Needs assessment of rural communities: a focus on older adults.

High-quality community needs assessments can help focus limited resources on the needs of a rapidly expanding population-older Americans. Based on such assessments, organizations and communities can effectively plan and deliver cost-effective, appropriate health promotion/wellness programs and health/social services to targeted populations. This article, which describes the Arkansas Aging Initiative's (AAI) use of a community needs assessment to identify its constituents' top health needs, provides specific background information for communities with demographics similar to those in Arkansas and offers assessment strategies for communities throughout the US. The AAI used two complementary methodologies to obtain critical input from Arkansas providers and their communities: focus groups of healthcare providers and community members and surveys administered to older adults. The assessment confirmed that health problems in the communities were consistent with leading causes of morbidity and mortality at state and national levels. It indicated that respondents' top three health needs related to affordability, including affordability of prescription medications, medical care, and health insurance, and that needs varied inversely with age. In other findings, married individuals rated their own health as better than their single counterparts; whites rated their health better than non-whites; and more than half of respondents reported leaving their counties to receive healthcare. This community needs assessment has enabled the AAI to address respondents' needs by developing specific educational and interdisciplinary healthcare initiatives, such as increasing access to a prescription drug assistance program.

An evaluation of provider educational needs in geriatric care.

Providers of geriatric care in Arkansas were surveyed to determine the desire for more information on their specialty as well as opportunities for further training. Those in the nursing profession were most interested in further training, and the major area of interest for all providers was in cognitive decline and mental health information. Specifically, information was sought in the areas of dementia, depression, and memory loss. It is recommended that improvement in geriatric care in the future should focus on nursing education and on raising the level of knowledge and academic prestige in the treatment of elderly patients, especially in the mental health areas.

Protein and older adults.

Body composition changes as people get older. One of the noteworthy alterations is the reduction in total body protein. A decrease in skeletal muscle is the most noticeable manifestation of this change but there is also a reduction in other physiologic proteins such as organ tissue, blood components, and immune bodies as well as declines in total body potassium and water. This contributes to impaired wound healing, loss of skin elasticity, and an inability to fight infection. The recommended dietary allowance (RDA) for adults for protein is 0.8 grams of protein per kilogram of body weight. Protein tissue accounts for 30% of whole-body protein turnover but that rate declines to 20% or less by age 70. The result of this phenomenon is that older adults require more protein/kilogram body weight than do younger adults. Recently, it has become clear that the requirement for exogenous protein is at least 1.0 gram/kilogram body weight. Adequate dietary intake of protein may be more difficult for older adults to obtain. Dietary animal protein is the primary source of high biological value protein, iron, vitamin B(12), folic acid, biotin and other essential nutrients. In fact, egg protein is the standard against which all other proteins are compared. Compared to other high-quality protein sources like meat, poultry and seafood, eggs are the least expensive. The importance of dietary protein cannot be underestimated in the diets of older adults; inadequate protein intake contributes to a decrease in reserve capacity, increased skin fragility, decreased immune function, poorer healing, and longer recuperation from illness.

Comparisons of vegetarian and beef-containing diets on hematological indexes and iron stores during a period of resistive training in older men.

OBJECTIVE: To test the hypothesis that older men who consumed a vegetarian (lacto-ovo) diet would develop a lower iron status compared with older men who consumed a beef-containing diet during a period of resistive training (RT). DESIGN: Experimental, repeated measures study. SUBJECTS: Twenty-one healthy men aged 59 to 78 years, with a BMI range of 24 to 33 kg/m(2), completed the study. INTERVENTION: All men consumed a vegetarian diet for 2 weeks (baseline). After this, the men were randomly assigned to one of two dietary groups. Eleven men consumed a beef-containing diet, and 10 men continued to consume a vegetarian diet for 12 weeks. During this time all subjects participated in RT three days per week, designated as RT1 to RT12. MAIN OUTCOME MEASURES: Serum ferritin and serum iron concentrations, transferrin saturation, transferrin receptor, total iron binding capacity, and selected hematological variables, as well as selected nutrient intakes and estimated iron bioavailability from three-day diet records, were determined at baseline, RT5, and RT12. STATISTICAL ANALYSES: A general linear model repeated-measures ANOVA was used to examine the effects of group, time, and group x time interactions for iron status and dietary data. RESULTS: Total iron intake was not different between the two groups; however, the beef group had a three to four times greater intake of bioavailable iron (P<.01) than the vegetarian group. Serum iron, total iron binding capacity, transferrin saturation, and transferrin receptor were not significantly different between the beef and vegetarian groups, or changed over time with RT. Serum ferritin decreased over time in both the beef and vegetarian groups during RT (P<.01). Re-introduction of beef into the diets of the beef group increased hemoglobin concentration and hematocrit compared with the vegetarian group during the 12 weeks of RT (group x time, P<.05). These changes were within clinically normal limits. APPLICATIONS/CONCLUSIONS: Older men who consume a beef-containing, higher-bioavailable-iron diet, compared with a vegetarian, lower-bioavailable-iron diet, have an increased hematological profile during a 12-week period of RT. Older men who consume either a beef-containing or a vegetarian diet maintain a hematological profile within clinically normal limits during 12 weeks of RT.