Avoiding Unintentional Weight Loss
Severe nutritional problems can frequently be found in residents of assisted living facilities, and could be the reason for their being there. Involuntary weight loss can lead to muscle wasting, decreased immunocompetence, depression and an increased rate of disease complications. Various studies also have demonstrated a strong correlation between weight loss and morbidity and mortality.
Unintentional weight loss in the elderly resident can be difficult to evaluate. This is especially true when the resident has multiple medical problems, is taking several medications, and has some degree of cognitive impairment. Studies reveal that the leading causes of involuntary weight loss in the elderly are:
- Depression, especially in institutional settings;
- Cancer, in particular lung and gastrointestinal malignancies;
- Cardiac disorders; and
- Benign gastrointestinal diseases.
Additionally, some medications may cause nausea and vomiting, dysphagia, dysgeusia, and anorexia.
Loss of lean body mass, a decrease in metabolic rate and changes in the senses and taste are all common as we age. By the age of 65, approximately 50 percent of Americans have lost teeth, resulting in chewing problems leading to decreased intake, serving as a complicated factor. A weight loss of approximately five to 10 percent of body weight in the previous one to 12 months may indicate a serious problem for a resident. This degree of weight loss should not be considered a normal part of the aging process.
To counter continued weight loss, management should develop plans to treat underlying causes and provide nutritional support. The following mnemonic, Meals on Wheels, is useful for remembering suspected etiologies:
||Emotional problems, especially depression
||Anorexia nervosa, alcoholism
||Oral factors (e.g. poorly fitting dentures, caries)
||Wandering and other dementia-related behaviors
||Hyperthyroidism, hypothyroidism, hyperparathyroidism, hypoadrenalism
||Eating problems (e.g. inability to feed self)
||Low salt, low-cholesterol diet
||Stones, social problems (e.g. isolation, inability to obtain preferred foods)
Keeping this mnemonic in mind, the facility's dietitian should complete a full nutritional assessment of the resident. The assessment should include a current review of the resident's weight history, oral intake at and between meals, consumption of supplemental foods, psychosocial changes, oral hygiene, dining skills, pertinent lab values, changes in medication and other medical and physical factors that impact weight. A review of estimated calorie, protein and fluid needs, as well as the resident's ability to meet those needs with interventions also should be completed. The resident's current weight should be compared to both the ideal weight range and usual body weight. The dietitian should document on all residents with significant weight changes at least monthly and more often as needed.
Meanwhile, the healthcare team should consider the resident's proper table placement, according to their preference and need for added assistance. The resident's service plan should be updated as interventions are put in place, and interventions should be tailored to the resident's preferences and needs. The resident's physician and responsible party should be notified promptly of the significant weight change and interventions that have been initiated.
Possible interventions could be added assistance with meals, adaptive equipment devices, etc. Staff should offer alternative foods to residents not consuming one half of any one or more food groups. The nursing or dietary staff should document both food and fluid intake after each meal and between meal snacks and supplements, per facility policy. All residents with unintentional weight change should be weighed on a weekly basis with scales that are routinely calibrated to ensure accuracy. Ideally, residents should be weighed with the same scale, on the same day of the week and wear similar clothing each time. If there's a significant fluctuation in weight between weeks, the scale may need to be adjusted and resident reweighed to ensure accuracy. All weights should be recorded in the resident's record and weight monitoring list for management review.
The facility's administrator should appoint an interdisciplinary weight change committee as part of their quality assurance and improvement process. The committee should meet weekly or monthly to discuss, plan and implement or revise interventions for residents that have been identified with unintentional weight changes. All decisions should be documented in the resident's record and/or service plan. Residents can be dropped from the frequent monitoring list per the facility's criteria, such as no weight loss for four consecutive weeks and the resident's weight remains within their usual or ideal body weight range.
Based on overall decline in health, the healthcare team, resident's physician and responsible party may determine a resident is expected to have a weight decline despite all facility efforts. Aggressive measures, such as parenteral or tube feedings, should be discussed with the resident and/or their responsible party, as appropriate. A refusal, with consequences stated, must be documented and signed by the resident and/or responsible party and placed in the resident's record as an advanced directive. An expected weight loss should be clearly stated on the resident's service plan with the factors that contribute to the resident's inability to meet estimated nutritional needs. At this point, the resident and/or responsible party may consider hospice and/or placement to a higher level of care.
Brooke Huffman, G (2002). Evaluating and treating unintentional weight loss in the elderly. Retrieved November 25, 2015 from http://www.aafp.org/afp/2002/0215/p640.html#