Weighing in on weight loss: in the elderly, unintentional weight loss sends a serious signal.

Unintentional weight loss is a common condition in the elderly and can affect up to 60% of nursing home residents. When unintentional weight loss occurs, it is an indication of declining health. Any weight loss of 5% or more of a resident's weight over a six-month period needs to be assessed, and its potential cause should be investigated. Increasing age, disability, coexisting medical illnesses, previous hospital admissions, low education level, cognitive impairment, smoking, loss of spouse, and low baseline body weight have all been associated with a higher likelihood of weight loss. (1)

[ILLUSTRATION OMITTED]

Unintentional weight loss causes a significant decrease in a resident's overall health and functionality. Weight loss increases a resident's risk for depression, infection, incontinence, anemia, and death; it causes lack of energy, fatigue, and weakness; and it can lead to function loss, pressure ulcers, and immobility complications. Other complications related to unintentional weight loss in the elderly include decreased cognition, falls, hip fractures, edema, immune system dysfunction, muscle loss, and osteoporosis.

Recognizing and Addressing Unintentional Weight Loss

A number of assessments can help to recognize treatable causes of weight loss. The initial clinical evaluation should include a medical history and physical examination to address any psychosocial, medical, or age-related causes. The medical history and physical should also include assessing for anorexia, dysphagia, weight loss despite normal food and fluid intake, and any socioeconomic factors. A nutritional history assessment upon admission or after a change in a resident's nutritional status can provide a number of reasons for weight loss. A thorough nutritional history assessment includes details such as a resident's height, weight, body mass index (BMI), medications, labs, caloric intake, food likes and dislikes, portion sizes, food restrictions, ethnic or religious food specifications, appetite, nourishment needs, swallowing problems, and dental evaluation. The dental evaluation specifies the general condition of the patient's teeth or dentures, and determines if dentures fit properly or are worn down. If a resident requires assistance or the use of any adaptive devices to eat, note this in the assessment. All of this information should be obtained from the resident and the family members. The clinical data should compare lab results and normal values. Lab tests that may provide insight to weight loss include:

* hemoglobin (Hgb)

* hematocrit (Hct)

* serum albumin (Alb)

* total protein (TP)

* transferrin (iron)

* sodium (Na+)

* potassium (K+)

* fasting blood sugar (Glucose or GLU)

* blood urea nitrogen (BUN)

* creatinine

* triglycerides (TRIG)

* cholesterol (CHOL)

* total lymphocyte count

In addition, a comprehensive pharmacologic history should be part of the initial medical history and physical. Multiple medications have been associated with unintentional weight loss in the elderly. Drugs that have been associated with unintentional weight loss include selective serotonin reuptake inhibitors such as Paxil, Prozac, and Celexa; cardiac agents such as Lasix, Lanoxin, and Vascor; amphetamines; appetite suppressants such as Adderall, Dexedrine, Cylert, Meridia, and Ritalin; and benzodiazepines such as Ativan and Klonopin. Other medications that should be noted include the following:

* antacids 

* antibiotics

* anticoagulants 

* diuretics

* potassium (K+)

* psychotropic drugs

* cardiac glycosides

* insulin

* oral agents

* anticonvulsants 

* laxatives

* vitamin/mineral supplements

* anti-inflammatories

In addition to the medications listed above, narcotics and sedatives can have a cognitive effect, interfering with a person's ability to eat. When decreasing a psychotropic drug, assess the resident for any signs or symptoms of the underlying disorder for which the drug was prescribed, since these can also contribute to weight loss. Examples include anxiety, behavioral problems, hallucinations, mania, and depression.

The most commonly identified causes of unintentional weight loss in the elderly can be summarized with the mnemonic "Meals on Wheels": (2)

Medications (e.g., digoxin, theophylline, antipsychotic agents)

Emotional problems (depression)

Anorexia tardive (nervosa) or alcoholism

Late-life paranoia

Swallowing disorders (dysphagia)

Oral problems (e.g., poorly fitting dentures)

Nosocomial infections (tuberculosis, Helicobacter pylori, Clostridium difficile)

Wandering and other dementia-related behaviors

Hyperthyroidism, hypercalcemia, hypoadrenalism

Enteric problems (e.g., malabsorption)

Eating problems (e.g., difficulty in self-feeding)

Low-salt, low-cholesterol diet

Stones (cholelithiasis)

Once you have recognized weight loss or have concluded that the resident is at risk for malnutrition, you must put a corrective action plan in place that treats and manages weight loss or risk for malnutrition with appropriate nutritional and medical support or treatment. If an underlying cause has not been determined and continued evaluation is required, an action plan with interventions to prevent additional weight loss is needed.

Improve Protocols to Manage Unintentional Weight Loss

Prevention through education is the most important step and should be the first application used. Know and understand the regulations and what is expected when your facility is surveyed. This information will help you to plan and implement the systems you must have in place, as well as identify any problems early on. Read your policy and procedures to make sure they are current and up to date. Make sure they are being implemented and then follow up for quality assurance. Complete a nutritional status review following admission at minimum intervals of 30, 90, and 180 days. Performing the necessary assessments will help you to identify potential problems, allowing for early intervention to be put in place.

Weekly team meetings and care plan meetings with members from all disciplines are important in identifying residents with potential problems before they become a survey issue. Every discipline plays a role in preventing weight loss and making sure the nutritional needs of residents are met. Referrals to registered/licensed dietitians, speech therapists, and occupational therapists allow you to use skilled personnel trained to identify problems and implement solutions. As a team, implement nutritional interventions and put protocols in place that are effective in the management of weight loss and malnutrition. Once protocols are in place, you must educate and train staff on how to recognize, document, and report any early warning signs or problems.

Improving your dining program and implementing effective protocols are crucial for achieving success and preventing survey issues. A successful dining program will improve residents' overall health. Having a pleasurable, calm, and relaxing dining experience can increase food and fluid intake, helping to prevent weight loss. Tour the kitchen and observe food preparation procedures and how meals are being served to your residents. Food should be prepared correctly, look appetizing, and arrive well presented. Menus should be well balanced and planned in advance with options for substitutions. Offer smaller, more frequent meals and allow a choice of portion size. Add special ingredients that stimulate appetites and enhance flavor; for example, cinnamon is a natural appetite stimulant that can naturally increase residents' appetites. In addition, the environment should be inviting and residents should be given enough time to eat, relax, and socialize.

Surveyors will be determining if the facility's protocols adequately address unintentional weight loss and if your interventions and responses were effective. They will have to decide if a resident's weight loss was avoidable. To decrease errors, documentation should be recorded at the time of consumption and not at the end of the shift. But while documentation is important, consistency and accuracy are even more so. For example, all staff members must be trained about portion sizes, and a standard of what your facility considers "bite-size" should be established to ensure consistent documentation.

Another way to ensure accuracy is to document what each resident ate at each meal and compare your documentation of food consumption with staff documentation. Are they consistent? Observe staff. Do they take time to help residents, feed them correctly, and encourage increased intake? And most importantly, does the resident feel cared for by staff's actions?

Conclusion

By implementing simple changes in protocols, you can decrease the occurrences of weight loss and avoid issues during surveys. Putting a system in place that accurately assesses your residents will help identify any risks. Using a team approach with referrals to the appropriate disciplinarians at the right time will allow for proper intervention. With a plan of care focused around prevention, intervention, and follow-up, you can have a successful program to avoid unintentional weight loss.

Phyllis Bouley, LPN, AS, is a Clinical Project Consultant for Briggs Corporation. For more information, phone [phone] or visit www.briggscorp.com.

To send your comments to the author and editors, e-mail [e-mail].

References

1. Alibhai SM, Greenwood C, Payette H. An approach to the management of unintentional weight loss in elderly people. Canadian Medical Association Journal 2005;172:773-80.

2. Morley JE, Silver AJ. Nutritional issues in nursing home care. Annals of Internal Medicine 1995;123:850-9.

BY PHYLLIS BOULEY, LPN, AS