Anorexia is an overall decline in appetite leading to decreased food intake, and consumption of inadequate calories. It is the major cause of weight loss and poor nutritional status in elderly persons[i]. Malnutrition and dehydration are associated with susceptibility to infections, cognitive impairment, poor skin and bone integrity, pressure sores and hip fractures. These serious consequences along with co-morbidities from chronic illness, often lead to mortality[ii]. A protocol to screen and assess elderly residents for nutritional risk is essential in establishing early interventions to diminish serious health effects of malnutrition.
A research group called the Collaborative Studies of Long Term Care, initiated in 1997 a series of multi-state projects that studied almost 5,000 residents in more than 350 retirement and assisted living communities published their findings in a special issue of the Gerontologist.[iii] Findings showed that low food intake was common in 54% of the participants and low fluid intake is prevalent among 51% of those studied in Long Term Care, particularly those with cognitive impairment. They found that residents who were closely monitored by staff during meal times are significantly less likely to have low food and fluid intake. Similarly, residents who eat their meals in a central dining area are much less likely to have low intake than those dining in their bedrooms. Often, in large facilities meal times are set and residents have limited time to consume their food. Pressured with time limits, staff can mistakenly assume that the resident is not hungry and removes much of the uneaten food before the resident is able to finish.
Physical examination can point to clear, visible signs of weight loss. Pronounced indentations at the temporal lobes commonly referred to as temporal wasting, loss of muscle mass, loose elastic skin, and decreased functional ability to perform activities of daily living (ADL’s) are all early indicators. Causes of weight loss are numerous and can include: swallowing difficulties, poor dentition, mouth pain, psychological disorders, depression, impaired mobility, and loss of appetite. Residents who begin to lose 5% of their weight in one month, or 10% over 6 months, or those who eat less than 75% of their food at meal times should be considered for a complete nutritional evaluation by a Registered Dietitian.
Operators should routinely evaluate body weight at the time of admission, and monthly thereafter. Use of the Body Mass Index[iv] (BMI) can help establish a baseline, and subsequent measures can point to clear trends of weight maintenance or decline. Residents who are determined to be high risk for weight loss can be identified in their chart and with a silicon bracelet. Staff will then notify and involve a registered dietitian who intervenes with an individualized food plan. Angela G. Sullivan MS RD consultant dietitian for Potomac Homes suggests, “The specific nutritional recommendations we make are in addition to a liberalized menu, offering favorite foods, and routine mealtime practices”. “The strategies and protocols for the resident at risk address prevention of continued weight loss and dehydration.” The emphasis is to make sure food and fluid are optimized at each meal, snack and hydration opportunity[v]. “Simply adding supplements is not enough to prevent weight loss”, she warned. Recommendations might include adequate texture changes for residents who have difficulty swallowing. Cutting up food, adding sauces and gravy to add extra moisture, and delaying the need to puree food are all strategies that focus on taste and appearance, and address quality of life. “Allowing residents additional time to complete their meal, offering assistance with feeding, using words of encouragement in addition to nutritional supplements and calorie dense snacks are protocols that can really make a difference,” She concludes.
Researchers followed weight loss trends of 1000 nursing home residents across the United States. They found many of elderly residents to be undernourished. During a six month period, 30% of those residents who continued to lose weight died. The study also found that 16-18% of elderly living in communities consume less than 1000 calories per day.
Clearly elderly that are at risk for weight loss who are treated with additional emphasis during meal times and throughout the day can greatly benefit, even avoid the early onset of nutritionally triggered catastrophic health failures. By recognizing at-risk residents early, operators can have a significant impact on the overall quality of life of their residents and help manage the acuity of care in their homes.
[i] Thomas, D.R., MD, Morley, J.E. Regulation of appetite in older adults. Clinical Strategies in LTC, a Supplement to Annals of Long-Term Care. July, 2002. Page 4.
[ii] Thomas, D.R. Progress Notes: Nutrition and Chronic Wounds. Supplement to Annals of Long-Term Care. November, 2004. Page 1-12.
[iii] Reed, Peter S., Zimmerman, Sheryl, Sloane, Philip, Williams, Christianna, and Boustani, Malaz. Characteristics Associated with Low Food Intake in Long-Term care residents with Dementia. The Gerontologist. Vol. 45 . October 2005. Page 74-80.
[iv] BMI uses a mathematical formula that takes into account both a person's height and weight. BMI equals a person's weight in kilograms divided by height in meters squared. (BMI=weight
kg/height m2). Mahan K. L., Escott-Stump S., Food Nutrition & Diet Therapy, 9th edition, Saunders., 1996, Appendix 18 pg 950-951