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was very disturbed and perplexed by the situation at one of the nursing homes where I was providing nutrition consultation services one day per week. Every Tuesday, as soon as I arrived, I was greeted warmly and handed a yellow legal sheet with the words "Weight Loss List" emblazoned on the top. Underneath this heading would be the names and room numbers of about 20 residents. These were the names of the residents who had been identified as suffering from involuntary weight loss (IWL). As the nutrition consultant, I was expected to spend my day finding out why and recommending interventions to halt further undesirable downward weight trends. It seemed simple enough.
       But each week I came across the same stumbling blocks. The residents on my special list had not been weighed. I was told, "One of the scales is still broken so we couldn't complete the weights." The meal intake records were incomplete. My recommendations from the previous week were still sitting exactly where I had left them.
       One day, a nursing assistant looked at me exasperated and begged to know what I was going to do about a particular resident. "Nancy, did you see her? She is a bag of bones. It breaks my heart." Later that day, the director of nursing took me aside and expressed deep concern about the IWL problem. During my exit conference that day, even the facility administrator was downright distraught about the number of residents that were losing weight. It seemed that every individual who worked in this facility was worried about the problem of IWL but didn't know what to do about it. After a few weeks of trying to come up with a plan, I realized that they treated IWL merely as a nutrition problem. The other disciplines didn't believe they had much to contribute. So they held their breath, marked the days off on the calendar, and waited for Tuesdays to come. We needed a new approach!

Identifying Involuntary Weight Loss
       Involuntary weight loss is a pervasive problem in the long-term care industry today. It is defined by a five-percent loss of body weight in 30 days, a 7.5-percent loss in 90 days, or a 10-percent loss in 180 days. To determine the percentage of weight lost, the following formula is used: (usual weight - current weight) ÷ (usual weight x 100). For example, if a resident usually weighs 130 pounds and currently weighs 120 pounds, this resident has lost 7.7 percent of his body weight. If this occurred over a one-month period, it would be considered clinically significant weight loss that requires appropriate intervention and documentation. An effective intervention and documentation program involves more than just the nutrition department. A commitment from every department in the facility is needed to form a truly multidisciplinary treatment team.

The Administration's Role
       The commitment must begin at the top of the corporate structure. The facility administrator must be willing to commit resources to this team. These resources are typically in the form of personnel. Many long-term care facilities contract with consultant registered dietitians for a certain number of hours per month. Often these hours are inadequate to properly monitor all the residents at risk for nutritional decline. These residents include those with IWL, pressure ulcers, tube feedings, parenteral nutrition, and certain medical diagnoses, such as uncontrolled diabetes or malabsorptive diseases. An evaluation of the adequacy and credentials of nutrition personnel should be conducted annually and adjusted as needed. Table 1 lists the different types of nutrition professionals. Resources also include sufficient personnel to assist at mealtimes, including the evening meal and the weekend meals, and adequate budgets for food supplies and kitchen operation and maintenance. Designated time for training and education must be provided. A facility culture emphasizing the importance of nutrition is paramount to the success of the team.

The Nursing Commitment
       Many long-term care facilities rely on the nursing staff to distribute meals, assist with feeding, and document meal intake. Each meal must be treated as an important one. Even missing one or two meals can begin a downward spiral for an elderly and infirm resident. The nursing staff is on the front lines in the battle against malnutrition and dehydration 21 meals and 21 snacks per week. It is understandable that meal duty may get tedious for the nursing staff. This is especially true if mealtime is a chaotic and stressful period. A review of the system used to distribute and serve meals may be in order. Many creative approaches can be tried, such as an "all hands on deck" policy or having the residents dine in shifts. Each facility is unique and should strive to find a solution that works for their specific population.
       Often, meal documentation is left as the final task of the day and not viewed as a vital part of the nutrition program. This is certainly not the case especially if your registered dietitian visits only once per week and, therefore, is not present at many meals. Accurate meal intake records provide valuable information for the nutrition staff. In addition, meal intake records are often stringently evaluated in nursing home litigation, as they are a part of the permanent medical record.
       The job of weighing residents often falls to the nursing staff as well. Training on proper scale usage is essential. There are many makes and models of scales, and each one operates somewhat differently. Accurate weights are imperative. Nurses communicate with the doctors most frequently and relay any weight changes to the physician and follow up on nutritional recommendations. It is important to document these conversations, so other team members can be aware of what has transpired.
       With all these nutrition-related tasks, it is obvious the nursing staff is critically important to the team. Creating a special nutrition team can foster team spirit and recognize nurses and aides who complete additional inservices or education in nutrition. For example, a special pin or uniform medallion can be given to those employees who attend 12 monthly nutrition sessions and then officially become part of the "IWL Prevention Team."

The Physician's Position
       The medical staff may include a physician, a physician's assistant, and/or a nurse practitioner. Diet and supplement orders must be given in a timely fashion and nutrition recommendations acted upon expediently. It may be most efficient to create nutrition protocols that allow trials of different dietary supplements and food textures in order to arrive at the optimal diet order as quickly as possible. The physician should not hesitate to consult with the registered dietitian if necessary. It is the dietitian's job to keep up with the latest nutritional products, so a good rapport and open channels of communication are necessary to facilitate diet changes and recommendations.

The Social Worker's Job
       At first glance, the social worker may not think that he or she has a role on the IWL team, but this department has a very important job. Living wills, powers of attorney, and do-not-resuscitate declarations must be in order. The social worker should provide education to the other staff members to clarify exactly what the nutrition portion of a living will means and when it goes into effect. It is a fallacy that IWL is acceptable just because a resident has a living will indicating he or she does not want a feeding tube. End-of-life issues are quite complex, and the social worker may be asked to take the lead role in assuring these topics are handled with the proper respect, timeliness, and consideration they deserve. The social worker is often the connecting link to the family members and can assure that proper information is being communicated to the family members as well as the resident. Again, documenting these discussions is vitally important as a method of communication between team members.

The Pharmacist's Role
       The long-term care consultant pharmacist is another nutrition team member who is often overlooked. But the pharmacist's role is growing in importance every day as more pharmaceutical agents are being used to treat IWL. The advent of appetite stimulants and anabolic agents, such as oxandrolone (Oxandrin, BTG Pharmaceuticals, East Brunswick, New Jersey), may raise questions that are best answered by a pharmacist. The pharmacist should educate the staff on proper dosing, proper timing of drug administration, and monitoring for adverse events. The pharmacist can provide useful recommendations on drug interactions that may cause anorexia, drugs that should be given with or without food, and information on all the latest pharmaceutical interventions to treat IWL.

The Activities Director's Task
       Food and eating should be fun. Just look at how many people eat at restaurants and socialize over food. The activities director is clearly an important part of the IWL team in long-term care by providing enjoyable food-related activities. Holiday parties, theme parties, socials, and even discussion groups can all include food and beverages. The activities director may be given the role of matching up suitable dining partners, introducing residents in the dining room, and encouraging mealtime socialization. The activities department can decorate the dining areas and be in charge of making it a pleasant place to eat.

The Maintenance Staff's Involvement
       Even the facility maintenance department is part of the IWL team. Scales are delicate instruments and should be properly maintained and calibrated. A successful weight-monitoring program cannot occur if the equipment malfunctions. A log documenting the scales' preventative maintenance program and calibration may be useful. Perhaps, the first of each month should be declared the day to check on the scales. Kitchen equipment also malfunctions, making it difficult to serve food. Ovens break, sinks clog, and freezers defrost. Preventative maintenance and proper care of equipment should become a part of the nutrition program.

The Rehab Department's Role
       The physical, occupational, and speech therapists are all important IWL team members. Many residents get tired eating and may not have the necessary strength to complete meals. Others may benefit from special feeding equipment, such as plate guards, sippy cups, or special eating utensils. Still others may require a diet texture modification, such as mechanical soft or ground food. The therapists can provide both useful insights and workable solutions to impediments to good meal intake. A properly nourished and hydrated resident may approach therapy with more zeal, so nutrition is just as important to therapy as therapy is to nutrition.

Family Members in the Loop
       Family members also play a role in preventing and treating IWL. Family members can be trained to assist with feeding and can encourage good meal intake. In our culturally diverse marketplace, many residents may enjoy favorite foods from home. Family members should be informed about the policy on bringing food from home and on safe food handling procedures. Information regarding weight trends and nutritional indicators must be communicated to the family members on a regular basis. Frank discussions about nutrition support should occur as soon as an IWL problem is identified. Family members should be provided with fair and balanced resource material in order to consider all available options. They may need support to understand that despite optimal nutrition intervention, IWL may still occur and may be a symptom of an end-stage disease. Thorough documentation is needed at every step, especially when several family members are involved or there are great geographical distances between the family and the resident.

The Winning Team
       It takes every department's cooperative effort to prevent, identify, treat, and document nutritional progress. Working together is the key to success. Each team member's unique contribution is valuable and needed. So go ahead--be creative, feel renewed, think of clever training and incentive programs, form a new team, call a meeting complete with a lot of tasty treats, and challenge the old systems in order to usher in a new winning interdisciplinary team.