The Nutrition-Focused Physical Exam in Long-Term Care

Older adults — especially those living in long-term care — are at an increased risk for malnutrition.

Consequently, malnutrition has been shown to increase the risk of falls and fractures, compromise the immune system, delay wound healing, and increase all-cause mortality risk.

As a component of a comprehensive nutrition assessment, the nutrition-focused physical exam (NFPE) can assist registered dietitians (RDs) in identifying malnutrition and micronutrient deficiencies in older adults living in long-term care.

RDs must be familiar with NFPE techniques and how they can use their findings to identify and document nutrition problems as well as develop a person-centered nutrition care plan in the long-term care setting.

Malnutrition in long-term care

Malnutrition is any deficiency, excess, or imbalance in nutritional status.

The Academy of Nutrition and Dietetics (Academy) defines malnutrition as an “Inadequate intake of protein and/or energy over prolonged periods of time resulting in loss of fat stores and/or muscle wasting including starvation-related malnutrition, chronic disease-related malnutrition, and acute disease or injury-related malnutrition.”

Malnutrition exists along a continuum from mild or moderate to severe and can be categorized according to its etiology — acute illness or injury, chronic illness, and social or environmental circumstances.

The Academy and the American Society for Parenteral and Enteral Nutrition (ASPEN) recommend six criteria — two of which must be met — for the diagnosis of malnutrition (1).

The six criteria include:

• including insufficient energy intake
• significant, unintended weight loss
• loss of muscle mass
• loss of subcutaneous fat
• localized or generalized fluid accumulation
• decreased handgrip strength

The prevalence of malnutrition in long-term care ranges from 12% to 54%, depending on the diagnostic tool used (2, 3).

Living in a long-term care facility itself is a risk factor for malnutrition in older adults – defined as 65 years or older.

Other malnutrition risk factors include (4):

• frailty
• polypharmacy
• dementia
• eating dependencies
• dysphagia
• constipation
• anorexia

These risk factors are commonly interlinked and occur as a consequence of another disease, condition, or medical treatment.

For example, polypharmacy — the concurrent use of multiple medications — can cause side effects that affect nutritional status, such as anorexia, constipation, and dysgeusia, or altered taste.

In addition to increasing costs of care and risk of hospital readmissions, malnutrition has detrimental consequences in older adults, including increased risk of falls and fractures, a compromised immune system, poor wound healing, and mortality.

Early screening for malnutrition leads to early detection and appropriate nutrition interventions. The nutrition-focused physical exam (NFPE) is a component of the nutrition assessment, that when performed accurately and compressively, can provide RDs with the necessary supportive data to identify and diagnose a person with malnutrition.

Although the NFPE is most often performed in the acute care setting, the NFPE is also appropriate and useful to perform in the long-term care setting.

Physiological changes of aging

Several physiological changes occur as a result of the natural aging process, many of which can adversely affect the nutritional status of older adults.

For example, sensory functions — including taste, smell, appetite, and vision — diminish, muscle mass and strength decline, and the immune system gradually deteriorates (5).

Aging is also associated with several chronic diseases, such as diabetes, cardiovascular disease, cancer, dementia, stroke, pulmonary diseases, and renal disease.

Compared with 50% of U.S. adults 45 to 65 years, 81% of U.S adults older than 65 years have more than one of these chronic diseases (6).

Chronic diseases can increase nutrient needs, but at the same time, make it more difficult to meet those needs. Dysphagia, or difficulty swallowing, is a common example prevalent in 13.4% of nursing home residents (7).

The condition commonly results from neurological diseases, including stroke, traumatic brain injury, dementia, and amyotrophic lateral sclerosis, and can result in reduced or altered oral intake of food and liquids.

Certain medications, cancers, and gastroesophageal reflux disease (GERD) can also cause dysphagia.

The multiple medications prescribed to treat one or more chronic diseases can also increase the risk of malnutrition in older adults.

The definition of polypharmacy varies, but it is usually defined as the concurrent use of five or more medications.

A review of 44 studies revealed that up to 91% of older adults in long-term care were taking more than five medications, with up to 65% taking 10 medications (8).

Some of the most common medication classes taken by older adults in long-term care include:

• analgesics
• antidepressants
• antihyperglycemics
• antihypertensives
• antiparkinsonian drugs
• antipsychotics
• diuretics

These medications have side effects that can adversely affect nutritional status in older adults, including:

• anorexia
• protein catabolism
• dysgeusia
• xerostomia
• nausea
• diarrhea
• constipation
• hypoglycemia
• fluid shifts
• nausea
• somnolence

Depression and poor oral health — while not normal physiological changes of aging — also increase malnutrition risk in older adults. Depression is more common in LTC residents than in community-dwelling older adults and is a major factor underlying poor appetite and unintentional weight loss (9)

Transitioning to LTC, bereavement, feelings of isolation from family and friends, and increased reliance on others for activities of daily living can all contribute to depression in older adults.

Similar to depression, older adults living in nursing homes have poorer oral health than older adults in the community (10).

Broken and missing teeth can make chewing certain foods uncomfortable and difficult. Dentures may be ill-fitting and cause mouth sores that can adversely affect chewing ability and lead to poor food intake.

Screening and assessing for malnutrition

Malnutrition screening is a quick and efficient process for identifying people who might be at risk for malnutrition. Several screening tools for malnutrition exist, but depending on the population and setting, they vary in their prevalence of use, sensitivity, and specificity.

For example, one review identified 34 malnutrition screening tools validated for use in older adults in the community and different healthcare settings (11).

While there is currently no agreed-upon gold standard to screen for malnutrition, studies suggest the Mini Nutrition Assessment – Short Form (MNA-SF) is the most suitable tool for use in LTC (12, 13).

The MNA is a screening tool validated for use in older adults aged 65 years and older who are malnourished or at risk for malnutrition.

Based on the full MNA, the MNA-SF consists of six questions on food intake, weight loss, mobility, psychological stress or acute disease, the presence of dementia or depression, and body mass index (BMI).

When height or weight cannot be obtained, calf circumference is used instead. Scores of 12-14 are considered normal nutritional status, 8-11 indicate at risk for malnutrition, and 0-7 may indicate malnutrition (14).

Malnutrition screening is not typically performed by an RD, but the RD is responsible for approving the screening tool and ensuring those who perform screening — such as nursing staff or the dietary manager — are trained in its use to triage nutrition care.

Screening and rescreening should occur on admission, quarterly, and after a significant change, such as an acute event or illness.

If a malnutrition screening tool such as the MNA-SF indicates that a resident might be at risk for malnutrition, an RD completes an in-depth evaluation of nutritional status. A nutrition assessment is the first step of the nutrition care process (Table 1).

It is a systematic process of obtaining, verifying, and interpreting data necessary to identify malnutrition or other nutrition-related problems.

Since there is no “gold standard” by which nutrition status can be defined or measured, RDs must rely on data and information obtained from food and nutrition-related history, anthropometric measurements, biochemical data, medical tests, and procedures, as well as the NFPE.

The Nutrition-Focused Physical Exam (NFPE)

The NFPE is a system-based examination of each region of the body to assess for physical findings related to nutrition, including changes in body composition, loss of subcutaneous fat, local or generalized fluid accumulation as well as micronutrient deficiencies.

The exam requires careful inspection and uses an assessment technique called palpation in which the examiner touches and feels the resident to determine texture, temperature, muscle rigidity, skin turgor, and tenderness.

Incorporating the NFPE in long-term care allows an RD to obtain a clearer picture of residents’ complex clinical conditions and identify nutritional issues that might otherwise remain unrecognized.

Many RDs, however, might lack experience or are not confident with their skills to perform an NFPE in the long-term care setting.

Putting the NFPE into practice

Just as a physician asks for permission and explains the rationale for an exam to a patient before examining them for any signs or symptoms of a medical condition, an RD must do the same with the NFPE.

Before beginning, the RD introduces themself to the resident and if present, family members or friends. The RD explains the rationale for the exam and then asks the resident for permission to examine them before washing or sanitizing their hands and donning single-use gloves.

It is best practice to also ask the resident about any tender or painful areas before assessing for muscle loss, subcutaneous fat loss, fluid status, and micronutrient deficiencies.

With the NFPE, the RD must differentiate the usual from the unusual.

Keep in mind that not every resident is a good candidate for an NFPE, especially fragile residents and those receiving comfort or hospice care. Residents might be combative or physically abusive, either because of advancing dementia or other reason, and therefore not be appropriate for an NFPE.

Assessing for muscle loss

Aging is associated with sarcopenia, the progressive loss of muscle mass and function that reduces mobility, diminishes the quality of life, and increases the risk of fall-related injuries, like hip or femur fractures (15).

Sarcopenia makes it difficult to discern age-related loss of muscle mass with muscle wasting in malnutrition, cancer, or another chronic disease.

Through collection and review of the resident’s food and nutrition history and other supportive data collected as part of a comprehensive nutrition assessment, the RD can better determine the etiology of muscle wasting if present.

Based on the physical characteristics, the RD can categorize their findings as normal nutrition status, mild to moderate muscle loss, or severe muscle loss (Table 2).

There are several areas to assess for muscle loss.

These include:

• Temple region (temporalis muscle). Look at the resident straight on and have them turn their head side to side. Palpate the muscle over the temporal bone and inspect for “scooping” or hollowing.
• Clavicular region (pectoralis major and deltoids). Palpate along the clavicle bone and look for “squaring” of the shoulders and loss of roundness at the junction of the shoulder and neck.
• Scapular region (trapezius, supraspinous, infraspinatus). If safe and appropriate, ask the resident to push on a hard object and inspect for prominent bones or depression between bones.
• Dorsal hand (interosseous muscle). Ask the resident to make an “OK” sign by touching their thumb and index finger together. Palpate the interosseous muscle and inspect for hollowing.
• Patellar region (quadriceps muscle). With the resident’s leg bent in bed, squeeze or gently pinch their quadriceps near the patella to differentiate muscle from fat.
• Posterior calf region (gastrocnemius muscle). Keeping their leg bent, have them engage their gastrocnemius by pointing or flexing their toes. Grasp and cup regions of the area to assess the muscle.

Assessing for fat loss

The progressive loss of skeletal muscle with age, along with an increase in body fat, is known as sarcopenic obesity.

Healthy muscles contain approximately 1.5% of intramuscular fat, whereas the intramuscular fat of older adults can reach approximately 11% (16).

This increase in intramuscular fat, as well as intrahepatic fat, promotes insulin resistance and metabolic syndrome, risk factors for cardiovascular disease, cerebrovascular accidents, and type 2 diabetes.

The largest increases in adipose stores in older adults occur primarily in intraabdominal fat rather than in subcutaneous fat.

Consequently, this can make assessing and interpreting NFPE findings for subcutaneous fat loss in older adults — especially those with a higher BMI — challenging.

Similar to muscle loss, fat loss can be categorized as normal nutritional status, mild to moderate fat loss, or severe fat loss based on physical characteristics (Table 3).

Examine the following areas for subcutaneous fat loss:

• Orbital region (surrounding the eye). Inspect and palpate under the eye and look for a loss of bulge under the eyes, characterized by a hollow look.
• Upper arm region (triceps and biceps). With the resident’s arm bent at 90 degrees, pinch the skin surrounding the triceps and biceps between the thumb and forefinger to determine the amount of fat present.
• Thoracic and lumbar region (ribs, lower back, midaxillary line). Examine the chest for visible ribs, and pinch above the iliac crest to examine the amount of fat present.

Assessing fluid status

Edema is an accumulation of fluid in the interstitial space of tissues, organs, or both that results in swelling. It can mask weight loss and result from malnutrition.

Examine and identify whether generalized or local fluid accumulation is present in extremities. Bilateral or generalized swelling may result from malnutrition.

When plasma proteins — namely albumin and globulin — are depleted from reduced protein synthesis, plasma oncotic pressure decreases, and the filtration rate across the capillaries increases (17).

This results in edema in skeletal muscle, skin, subcutaneous tissue, intestines, and heart. Rule out chronic conditions that are commonly associated with edema, such as congestive heart failure, liver cirrhosis, and renal diseases before using fluid retention as a sign of malnutrition (Table 4).

Several classes of medications are also associated with edema, including antidepressants, antihypertensives, chemotherapeutics, hormones, and nonsteroidal anti-inflammatory drugs.

Fluid accumulation associated with malnutrition can occur in the extremities — medial malleolus, bony portions of the tibia, and the dorsum of the foot — of mobile residents and in the sacral region of immobile residents.

Evaluate edema for pitting and tenderness.

Pitting is the indentation that remains in an edematous area after pressure is applied. Tenderness or pain from palpation of the edematous area is associated with deep vein thrombosis (DVT).

To assess for peripheral edema, press your thumb or index finger on the medial malleolus, bony portions of the tibia, and dorsum of the foot for at least five seconds. If a pit or depression develops, determine the depth and time the indentation lasts (Table 5) (18).

Dehydration

Dehydration is a condition that results from an excessive loss of body water with or without sodium.

Older adults — especially those in long-term care — are at an increased risk for dehydration for several reasons.

Risk factors for dehydration in older adults include (19):

• polypharmacy
• incontinence of bladder, bowel, or both
• cognitive impairment
• fever
• multiple chronic diseases
• bedridden
• eating dependencies
• malnutrition

Several phycological changes that occur during the aging process also increase dehydration risk. These changes include decreased thirst mechanism, less total body water, and decreased kidney functions.

Depending on the methods for diagnosing dehydration, the prevalence of dehydration in nursing home residents ranges between 0.8% and 38.5% and is associated with various adverse effects (19).

Adverse effects of dehydration include:

• delirium
• falls
• constipation
• urinary tract infections
• renal impairments

While frequently conducted to assess for dehydration, the reliability of physical examination has been questioned.

The symptoms commonly associated with dehydration in older adults include decreased skin turgor, sunken eyes, and dryness of the mouth, skin, and axillary.

These symptoms, however, have been shown to have low sensitivity and specificity as markers for identifying dehydration in older adults (20).

That said, NFPE techniques may hold little utility for assessing hydration status in older adults.

Currently, no gold standard or minimally invasive test exists for accurately identifying dehydration in older adults, however, missing drinks between meals have been linked with dehydration.

RDs can educate residents and their families and friends as well as nursing home staff on the importance of hydration and ways to increase hydration in the older adult.

Assessing micronutrient status

Older adults are at risk for deficiencies in micronutrients related to decreased food intake, malabsorption, increased nutrient needs, disease process, and use of certain medications.

For example, older adults are at an increased risk for vitamin D deficiency because of declining kidney function, low dietary intakes of vitamin D, decreased sun exposure, and overweight and obesity.

Vitamin B12 deficiency is also common in older adults due to atrophic gastritis, the chronic inflammation of the stomach lining that decreases the body’s production of hydrochloric acid, which is necessary for vitamin B12 absorption.

Older adults are also more likely to take medications that interfere with vitamin B12 absorption, such as antacids and metformin.

Various clinical and physical changes result from micronutrient deficiencies or other causes that can be non-nutrition-related (Table 6).

Examine the following areas for signs and symptoms of micronutrient deficiencies (21):

• Skin. Observe for hyper- or hypopigmentation, redness, pallor, cyanosis, and yellowing. Asses for moisture, temperature, lesions, and turgor.
• Head/hair. Inspect the hair for quantity, distribution, texture, and color.
• Eyes. Ask if the resident has changes in night vision. Observe the color of the sclera, conjunctiva, and cornea.
• Oral cavity. Observe for swelling, color, dentition, lesions, or sores of the mouth, tongue, gums, and teeth.
• Neck. Inspect and palpate the neck.
• Nails. Inspect the nails for color, texture, shape, and lesions.

Documenting malnutrition

After completing the NFPE, document the gathered information in the resident’s medical record.

If the assessment indicates that no nutrition problem currently exists that warrants a nutrition intervention, document no nutrition diagnosis at this time.

Conversely, if making a diagnosis of malnutrition or other nutrition-related diagnoses, include supporting information from the NFPE in the nutrition diagnosis statement, and communicate the findings with members of the interdisciplinary team.

The Centers for Medicare and Medicaid Services (CMS) transitioned to a new payment model on October 1, 2019, called the patient-driven payment model (PDPM).

The PDPM replaces the long-standing prospective payment and resource utilization group (RUG-IV) with a new model that focused on the unique, individualized needs, characteristics, and goals of residents under a Medicare Part A covered stay in a skilled nursing facility (SNF).

Under PDPM, CMS recognizes certain conditions and services — one being malnutrition — that are associated with increased costs, that if present, increase facility reimbursement (22).

This increased reimbursement is designed for the facility to increase the use of appropriate services, such as medical nutrition therapy by an RD.

That said, if it is determined that a resident is malnourished upon admission to an SNF under a Medicare Part A covered stay, it is particularly important to communicate that diagnosis with the resident’s physician, physician assistant, or nurse practitioner, as only these providers can document a diagnosis of malnutrition in a resident’s medical chart.

Faxing the resident’s provider with the findings and supporting data for a diagnosis of malnutrition is typically the quickest and most efficient way to obtain an active malnutrition diagnosis from the care provider which can then be coded in Section I of the Minimum Data Set (MDS) 3.0.

Other conditions and services relevant for RDs that increase reimbursement under PDPM include parenteral and enteral feeding, and morbid obesity, defined as a BMI ≥ 40 kg/m².

The nutrition intervention should be aimed at resolving the underlying cause of malnutrition. When this is not possible — as with physiologic or metabolic changes — the nutrition intervention should aim to minimize the signs and symptoms of malnutrition.

In either case, ensure that the nutrition intervention is person-centered by keeping the resident at the center of care planning and the decision-making process.

Set goals and determine expected outcomes with the resident, define the time and frequency of care, and determine the appropriate indicators to monitor and evaluate the effectiveness of the chosen nutrition intervention.

Determine whether the nutrition intervention strategy is meeting the desired outcomes with additional nutrition assessments, including NFPE findings, and revise the nutrition intervention as necessary.

Continue to document and update the resident’s care plan at regularly scheduled intervals regarding future plans for nutrition care, nutrition monitoring, and follow-up or discharge from nutrition care.

The bottom line

With a high prevalence of malnutrition in residents living in long-term care, RDs are in a unique position to utilize the NFPE as a crucial component of a thorough nutrition assessment if malnutrition or a nutrient deficiency is suspected.

The NFPE establishes a more accurate confirmation that a nutrition problem is present, and it can define the degree of malnutrition, when used in conjunction with other parameters of a comprehensive nutrition assessment, including food and nutrition-related history, anthropometric measurements, biochemical data, medical tests, and procedures.

As a result, the NFPE helps identify and support nutrition diagnoses like malnutrition and provides objective data for effective person-centered nutrition interventions in the LTC setting.