Grampa looks thinner: addressing resident malnutrition.

Mr. Parker sits in his room awaiting the first meal of the day. Down the hall, someone rolls a squeaky meal cart full of institutional meal trays--sanitary and clean.

When the lid is lifted off, he finds a gleaming white plate with a lukewarm, solid mound of scrambled eggs, links of rubbery sausage and slices of soggy toast. He didn't even smell it coming. Does this sound familiar? Breakfast is the most important meal of the day for everyone--particularly elders, who tire as the day wears on. Yet missing simple things, like seeing the food prepared and the familiar aromas of brewed coffee and toast, affect the appetite.

In a recent supplement to the Annals of Long Term Care, Dr. John E. Morley and his colleagues discussed the concerns of weight loss in the elderly, institutionalized population in stark contrast to the nation's ever-burgeoning obesity epidemic.

While weight gain in the general population sends up red flags because of its associated health risks, weight loss in the elderly population should also raise an alarm because of its association with increased rates of disease and death.

Practitioners have long dealt with the challenges of weight loss in the elderly population. "In the last five years the health and nutritional status of our elders has declined immensely," said Ann Marie Kraus, a registered dietitian at Tioga Nursing Facility in Waverly, N.Y.

"The residents admitted today are much sicker and debilitated than in recent years. Often it is after a hospitalization or major surgery that they come to us," she said. "Weight loss and nutritional deficits already have a good start by then."

While it is impossible to uncover every cause of weight loss and guarantee positive outcomes in every situation, Morley's research has shed light on a number of causes that will give clinicians new insight and potentially new ways to meet the challenge of acute and chronic weight loss.

Morley noted many physiological changes with aging that can affect food intake to a great degree. For instance, as we age, we tend to eat less food, despite the fact that weight generally increases as we approach middle age.

The slight declines in the ability to taste and smell occurring with advancing age can also contribute to diminished intake. Older residents tend to feel full faster as a result of muscular changes in the stomach wall and increased levels of gastric hormones that signal satiety.

There currently is no recourse for these concerns. "It is very difficult to meet the nutritional needs of someone who is sated with minute amounts of food," Kraus said. "The use of high calorie, high protein foods and supplements becomes an absolute necessity."

Many of these changes are the body's response to the slowed metabolism with aging. In effect, it is the body's defense mechanism to prevent excesses of weight gain that would be detrimental to a body that is not able to adjust to the physical and physiological stresses of obesity.

In some individuals, however, these defense mechanisms take over and what results is a failure to thrive, otherwise known as the "dwindles."

Kraus said, "Failure to thrive is very common, particularly in post-surgical residents who do not consume enough nutrients to support the healing process in addition to the baseline nutritional needs,"

The scientific evidence and the theoretical foundations of weight loss in this population are significant, but by far the importance lies in putting the scientific and theoretical into practice. While we cannot slow or reverse the physiological changes of aging and the impact on food intake, we can take steps to better identify those at risk of weight loss and malnutrition and be open minded to the myriad of causal factors and treatment options.

So, what are cutting edge clinicians doing? They point to accurate food intake recording as potentially the best tool to monitor persons at risk for malnutrition and weight loss in the institutional setting. Regular and accurate weight measurement is another.

Unfortunately, studies have shown that both of these are highly inaccurate in the nursing home setting, and are generally not even done in an assisted living setting, where ironically most declines in weight and nutritional status can start.

All hands on deck

Mary Johnson, clinical nutrition coordinator at Cortland Care Center in Cortland, N.Y., said, "The key here is diligent staff training--continuously. With the high turnover in first line caregiver staff in the health care industry today, training needs to be ongoing."

One continuing education session a year for certified nursing assistants to make them aware of nutritional and hydrational concerns in this population is not pragmatic.

Johnson said weight loss is an interdisciplinary problem requiring an all hands approach. "All staff need to be aware of the importance of accurate food intake records and weights all the time. The more you educate staff and keep it foremost in their minds, the sooner they'll buy into the importance of accuracy in documentation and proper weighing protocols."

In addition to diligent record keeping and monitoring, many facilities have turned attention to the pleasurable qualities of food to prevent weight loss. Particularly successful are meals served from a steam table on a nursing unit or served family style to enhance the sensory appeal. Making breakfast on the nursing unit, or in the main dining room, is a fantastic way to get appetites revved up for the whole day. Smelling coffee brewing, bacon frying and bread toasting does wonders for an appetite that is dulled by medications or the ravages of the aging processes.

Tamara Chandler, certified dietary manager at Sayre House in Sayre, Pa., described the facility's Sunrise Cafe event as a popular one for all of the residents. "When we prepare breakfast in the dining room, appetites excel," she said. "People who normally pick at their meals ask for seconds and thirds. Even those who usually eat and run linger for more coffee and conversation"

For facilities that may not be able to do this due to budget, staffing or space constraints, she suggested having a toaster handy to make additional toast while breakfast is being served.

Care needs to be taken, however, with residents who are on mechanically altered diets. The sensory appeal of blobs of pureed foods or mounds of ground foods does little to whet the appetite. Chandler admitted, "Eye appeal is everything, and making plates look neat, garnished, and appealing can go to great lengths in increasing consumption. We try different techniques to make it look as attractive as possible."

Fortified foods tend to provide more nutrients per spoonful than their regular counterparts. Liquid supplements can replace or add calories and nutrients to the diet. Since they do not stay in the stomach like solid foods, they do not contribute to early satiety and may be the most efficient option available to halt a weight loss when nothing else seems to be effective.

"If someone's appetite is poor-whatever the reason--the nutrient density of what little they do consume is a critical factor to consider," Kraus said.

She added, "For someone who is consuming very little, think small frequent offerings of very nutrient-dense items and encourage liquid or semi-solid foods" which will pass into the small intestine quickly without causing excessive fullness.

Check the meds

An often forgotten but integral member of the interdisciplinary team when weight loss occurs is the consultant pharmacist. A handful of pills and a glass of juice or water can constitute the volume equivalent of a meal for some elderly residents.

A monthly review of medications and a watchful eye regarding the use of medications that may cause anorexia and weight loss can head off potential problems. Many facilities have done well reducing the number of medications each resident receives, but more could be done to prescribe wisely, being aware of the potential side effects.

Kraus said that in her facility also involves the social worker when weight loss occurs. "If someone is losing weight, we notify the social worker to complete a Geriatric Depression Scale and we use antidepressants liberally," she said.

Studies have shown that depression is under-diagnosed and under-treated in the elderly population. And, depression is one of the leading causes of weight loss in the institutionalized elderly population.

Biochemical indices can also give clues regarding weight loss, but most are after-the-fact measures. Though subtle changes can be noted in visceral proteins over time, reduced food intake, weight changes, and medications, hormonal changes, chronic illnesses and infections all affect the indices.

While helpful at times, biochemical indices shouldn't be relied upon solely as indicators of malnutrition in the elderly population. Experts recommended looking for the obvious--clinical signs and symptoms as well as monitoring intake records and weights for subtle changes.

Increasing awareness of the causes of weight loss, whether they are related to the aging process, medications, or chronic illnesses should be the first line of defense in prevention.

Assisted living facilities can boost awareness by noting food intake patterns of residents or subtle changes in intakes. These are the earliest symptoms that something is awry. Nursing facilities can also implement continuing education sessions for all staff.

Greater attention to the social aspect of mealtime and the hedonistic qualities of the food are simple, cost-effective interventions. Starting out with well-balanced, popular menu items and sufficient meal choices, then enhancing them with adequate seasoning, garnishes and a pleasant social atmosphere will save on the tangible and intangible expense of weight loss complications such as pressure ulcers, increased infection rates and hospitalizations.

A Thin Line

When thinking about abuse at nursing homes, one tends to focus on physical and verbal forms. The number of malnourished residents, however, has sparked a growing concern that residents are being abused or neglected.

"Malnutrition is not a natural occurrence of aging," said Barney Spivack, M,D., president of the Connecticut Geriatrics Society and director of medical services at Waveny Care Network of New Canaan, Conn.

Many times people enter facilities already at less than their ideal weight, he said. "Their appetite is poor, they may not have had access to adequate food, and many are in nursing homes because of dementia, so they've had difficulty in preparing food. It takes time to get back to where they should be because they are now in a different environment, with different people surrounding them and foods they are not used to."

The Council for Nutrition/Clinical Strategies in Long Term Care of Newtown Square, Pa., puts the numbers of malnourished LTC residents at 20-54 percent.

A June 2000 report by the Washington, D.C.-based National Citizens' Coalition for Nursing Home Reform stated 35-85 percent of nursing home residents during the previous decade were malnourished.

Jerold E. Rothkoff, an attorney based in Cherry Hill, N.J., represents families and victims of nursing home abuse and neglect. He said inadequate staffing exacerbates the malnutrition problem. "If a resident is staring at his plate and doesn't have help to eat the food, what good is a nourishing meal? Some facilities insist that the families come in to assist the resident at mealtime. But that's not what they're spending upwards of $7,000 a month for."

"It can happen at home, too" said Robert Bauman of the Bauman & Rasor Group of San Jose, Calif., a private investigator who works with attorneys on nursing home abuse cases. "But I don't think it happens as often because it's more one-on-one as opposed to facilities where one aid has to care for five, 10 or 12 residents."

As pernicious as inadequate staffing can be, a proactive approach offers a respectable supplement. As part of the research effort that will hopefully stem the problem, Dr. Spivack offered some suggestions, "Assess people as they come in for the risk of nutritional deficits. This should be done by a nutritionist.

"Management approaches should then be developed. Understand the preferences of each person, make sure consistency is perfect, and if a person suffers from dementia and lacks the ability to use utensils properly, offer finger foods."

He also suggested using pleasant smells to stimulate appetites, and serving in small group settings to make the experience more homelike. "Because everyone likes to eat."

--Tobi Schwartz-Cassell

Christina Hasemann, Ph.D., R.D., L./C.D.N, a registered dietitian, is the President/CEO of NY-Penn Nutrition Services, Inc. a healthcare consulting firm in Binghamton, N.Y., and an adjunct instructor at Broome Community College and Morrisville State College (Norwich Campus). She can be reached at [e-mail].