MDS Alert

Talking to residents about their appetites can illuminate red flags.

Eating or nourishment happens every day, and paying attention to a resident’s habits and any fluctuations can provide you with clues about important systemic changes. When completing Section D, consider your resident’s eating habits and how they reflect upon his mood through interview. If you cannot conduct an interview, you can assess his mood.

Remember: Section D should not be used as the basis for diagnosing depression or another mood disorder, but it’s the correct place to record specific signs and symptoms that could indicate a mood disorder.

Any deviation such as poor appetite or a sudden tendency to overeat could flag the onset of depression or another mood disorder, especially if another physical change or diagnosis also presents. Careful interviewing and observation are key to noticing and documenting changes in appetite, but further investigation is crucial for your next steps in care-planning.

“In the nursing home environment, many residents have difficulty expressing their needs. Often times, dementia is mistakenly diagnosed. In these cases, a heighted focus on behaviors is critical as depression can manifest itself through persistent complaints of pain, headache, exhaustion, restlessness, tearfulness, pacing and fidgeting, along with gastrointestinal issues,” says Kris Mastrangelo, President and CEO at Harmony Healthcare international (HHi) in Topsfield, Massachusetts, in a blog post.

The RAI Manual says that mood distress is “a serious condition that is underdiagnosed and undertreated in the nursing home and is associated with significant morbidity. It is particularly important to identify signs and symptoms of mood distress among nursing home residents because these signs and symptoms can be treatable.” The sudden onset of poor appetite or overeating could be a flag for mood distress, and you can use mealtime to search for the underlying causes and potentially curb these behaviors.

Utilize your Interviewing Skills in Section D

When you code D0100 (Should Resident Mood Interview Be Conducted?) 1 (Yes), you or a team member must conduct a one-on-one interview with the resident, with careful, considerate, probing language. If you code 0 (No), skip to D0500 (Staff Assessment of Resident Mood …).

In Item D0200 (Resident Mood Interview [PHQ-9^©]), record the resident’s evaluation of his own appetite.

The lookback period for both D0100 and D0200 is 14 days; code answers to all parts of D0200 (Resident Mood Interview …) for both symptom presence and symptom frequency. While interviewing, listen for answers that a resident may couch in different descriptions.

For example: Mr. Collins says that he hasn’t been eating because he doesn’t like the texture or flavor of the food because it’s always too mushy and has no salt. You repeat back to him that you understand that he doesn’t like the texture and that he misses the flavor of salt, and then ask him how often he felt this way in the past two weeks.

Remember: You’re recording whether he has been eating or not eating; don’t get sidetracked by the comments about the food. It’s appropriate, in your care-planning process, to have the dietician or food service supervisor review his likes and dislikes and offer upcoming meal menus, which might help improve his mood and eating habits, says Marilyn Mines, RN, BC, RaC-Ct, Senior Manager at MarcumLLP, in Deerfield, Illinois.

Section D (Mood) evaluates a resident’s mood according to whether you believe the resident requires a mood interview, and whether you conduct one by conversation with the resident or through your own observation. Use sub-item D0200E (Resident Mood Interview, Poor appetite or overeating) to evaluate a resident’s appetite through the resident’s perspective.

How to Code: In evaluating the incidence of poor appetite or overeating, code sub-item D0200E1 (Resident Mood Interview, Poor appetite or overeating) with the following options:

• 0 (No),
• 1 (Yes), or
• 9 (No response).

If you code 1 (Yes) for D0200E1 (Resident Mood Interview, Poor appetite or overeating), you will also need to record the frequency of poor appetite or overeating by coding:

• 0 (Never or 1 day),
• 1 (2-6 days, several days),
• 2 (7-11 days, half or more of the days), or
• 3 (12-14 days, nearly every day).

If you believe the resident does require a mood interview but you cannot have a conversation with the resident, you should complete item D0500 (Staff Assessment of Resident Mood …). You can evaluate your observation of poor appetite or overeating, which could be symptomatic of a mood disorder, in sub-item D0500E. To code D0500E1 (Staff Assessment of Resident Mood, Poor appetite or overeating, Symptom presence), choose one of the following options:

• 0 (No),
• 1 (Yes), or
• 9 (No response).

If you code 1 (Yes) for D0200E1, you will also need to record the frequency of poor appetite or overeating to complete D0200E2 (Staff Assessment of Resident Mood, Poor appetite or overeating, Symptom Frequency). Choose one of the following:

• 0 (Never or 1 day),
• 1 (2-6 days, several days),
• 2 (7-11 days, half or more of the days), or
• 3 (12-14 days, nearly every day).