costs, although clearly, for some patients who wish to avoid institutionalization and still maintain acceptable levels of quality of life and health, there is no other alternative.43,73

Increasing numbers of the very old are institutionalized during their final years of life, and in such settings the adequacy and appropriateness of the food served to them vary greatly. The simple fact of residence in a long-term care facility does not imply immunity from malnutrition or undernutrition. Indeed, several studies show that the nutritional status of residents of long-term care facilities leaves much to be desired.98 It is difficult to evaluate these groups, however, because some of the supposed indicators of nutritional status among elderly patients may be altered for nonnutritional reasons (e.g., disease).96 In addition, although biochemical tests of malnutrition are useful, they vary greatly in their specificity and sensitivity, especially in the elderly. There is as yet no generally agreed upon battery of tests that will provide accurate assessments of risk.59

The benefits of inpatient nutritional care have recently been reviewed.23 Among the most cost-effective strategies are weekly nutrition rounds, made with the dietary supervisor, a consultant dietitian, and a registered nurse, to assess patient status. The results of such sessions have been generally positive and include improved dietary intake, weight status, bowel status, and skin health; the costs associated with the sessions were less than those associated with conventional procedures. Other studies have shown that the use of high-fiber (bran) diets among elderly institutionalized patients can dramatically decrease laxative abuse. Because the amount of time presently devoted to dietetic surveillance is only 10 minutes or less per patient per month, efficient means for nutritional care assessment, intake evaluations, counseling, and documentation need to be found. It is also essential that dietitians develop more services in these areas and that funding be made available to investigate the cost-effectiveness of such services.

The nutrient intake of elderly long-stay hospital patients is often inadequate; in fact, those patients whose healing is the most retarded often prove to have the poorest intake. Attention to dietary intake may be particularly helpful in some cases to stimulate healing postsurgery. For example, malnutrition adversely affects the prognosis for lower limb amputations, but it seems to have less effect on more proximal amputations.56 Similarly, certain biochemical parameters associated with malnutrition (e.g., reduced serum albumen, transferring, absolute lymphocyte count, energy) are associated with both morbidity and mortality. Furthermore, patients judged to be malnourished at

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