W

hile puzzling over a patient’s chart, trying to identify the cause of his weight loss of 10 lbs, my stomach growls. Without looking at my watch, I know it must be about 11:00 AM, the time I always get the signal that I am hungry. As I try to push aside these feelings and convince myself I can hold off eating for another hour, I see the irony in my life. From a personal standpoint, I deal with hunger daily and make conscious choices on what to eat to prevent myself from gaining weight. Yet professionally, as a registered dietitian (RD), I find myself much more concerned with a very different weight problem—lack of appetite and unintended weight loss in residents in long-term care facilities.

Types of Weight Loss

       Unexpected weight loss is a hot topic in long-term care. While some contend that weight loss is an inevitable part of the decline faced before death, every case of weight loss, whether gradual or rapid, must be carefully examined. Not only is this in the patient’s best interest, it is also a regulatory requirement. During its annual visit to the facility, the survey team must determine whether the facility identified unintended weight loss and attempted to intervene when weight loss was noted.

Table 1

       Involuntary weight loss is defined as any unplanned weight loss from the usual adult body weight. The phrase “usual body weight” is key to understanding how weight loss is evaluated. Usual body weight is the weight that is considered normal for a patient in recent months. This differs from “ideal body weight,” which is the ideal weight for a person’s height. While the ideal body weight is readily available (using charts or a quick calculation), usual body weight must be obtained from the resident and/or his or her family. Sometimes it is hard to obtain a usual body weight from a confused or very ill elderly person. However, it is key to evaluating a patient’s weight status and should be included in admission interviews with the resident and family.
       The Resident Assessment Instrument (RAI) of the Centers for Medicare & Medicaid Services (CMS) considers weight loss “significant” when it reaches 5% in 30 days or 10% in 180 days. If a resident shows a significant weight loss, some form of intervention should occur. Slow weight loss trends do not trigger as significant but are clear indicators of a change in the resident’s status and should be considered serious. While 1 or 2 lbs a month may not seem like a lot, it should be addressed if it continues for more than 2 months.

Resident Evaluation

       To evaluate residents for weight loss, long-term care facilities should have policies and procedures in place. A multidisciplinary committee that includes all disciplines (eg, nursing, social, speech, activities, dietary, and occupational therapy) should meet regularly. Facilities should weigh residents at least monthly. If weight loss is noted, weekly weights should be initiated, and the family, doctor, and RD should be notified. Timely and accurate weighing upon admission and during regular intervals is critical to evaluating weight loss. If weight loss is noted, the resident should be re-weighed. If possible, residents should be weighed at the same time of day, using the same method (ie, standing, wheelchair, lift, etc.) and in the same type of clothing to minimize variation. Staff members who weigh residents should understand the importance of accuracy and report weight losses immediately.

Table 2

       Should a facility be concerned about weight loss in an obese resident? Yes! Significant weight loss in the obese patient can be as much of a concern as it is in an underweight patient. Even in the overweight resident, weight loss below his or her usual body weight may be a sign that there is a change in the health of the resident. In some cases, an obese resident wants to lose weight or might benefit from weight loss because of his or her medical condition. This resident can be care-planned for weight loss, but the rate of weight loss should be closely monitored.
       Often, weight loss is more complex than just a decrease in appetite. Certainly, the combination of medications a resident takes may affect his or her appetite. Even a sudden illness can cause a decrease in appetite. But weight loss can also be associated with a decline in cognition, causing confusion at mealtime. A decline in physical status may result in a decline in feeding ability and, therefore, weight loss. A worsening or undiagnosed medical condition, a sore mouth or ill-fitting dentures, and undiagnosed depression are all causes of weight loss.

Table 3

       Key to choosing interventions for weight loss is accuracy of flow sheets documenting the resident’s intake of meals, snacks, and supplements. If flow sheets indicate that meal intake is good, extra portions and/or snacks can be ordered. If meal intake is poor, food likes and dislikes should be revisited with the resident. Discontinuing a therapeutic diet may result in an increased meal intake but should only be done with input from the RD. Fortified foods are another good approach for the poor eater. Butter and other high-calorie foods or food supplements are added to foods like oatmeal, mashed potatoes, and soups, providing more calories per bite. Supplemental nutrition in the form of shakes between meals or a 2-calorie medication pass may be needed for the poor eater. A 2-calorie medication pass is often accepted by residents and provides around 180 calories in only 3 ounces of liquid.
       Sometimes a resident is noted to be pocketing food or having trouble swallowing foods and beverages and therefore eating less. The facility speech therapist can easily determine if a change in texture may benefit the resident’s meal intake and prevent continued weight loss.

Treatment Approaches

       When a resident is losing weight, the facility should assess the dining environment. Knowing a resident is key to providing the best possible environment and assistance. While one resident will benefit from socialization at mealtime, another may eat best in the calm environment in his or her room. If a resident who normally feeds himself or herself is suddenly needing more assistance, he or she may need to be moved to a different table or require evaluation by the occupational therapist.
       If changes in diet, environment, and feeding assistance have been attempted and weight loss persists, medications should be evaluated. Before ordering an appetite stimulant, look at the resident’s current medications to see if any might be affecting his or her nutritional status. Many medications have side effects that might interfere with taste or cause anorexia.² Drug therapy to stimulate the appetite should not be considered without attempting other interventions first. The Food and Drug Administration (FDA) has not labeled any medications for use in the elderly and few have been studied in this population.² Medications commonly prescribed include REMRON^® (Organon USA, Inc.), an antidepressant that has been shown to increase appetite while also treating depression. Others include MEGACE^® (Bristol-Myers Squibb), for treatment of anorexia in AIDS and cancer patients; cyproheptadine, an antihistamine that may increase appetite; and ELDERTONIC^® (Merz Pharmaceuticals, Inc.), a mixture of vitamins and minerals.
       A resident will sometimes continue to lose weight despite multiple interventions. Attempts should be made to slow or stop the weight, and advance directives regarding tube feeding should be obtained and documented. If the patient/family does not want tube feeding, the weight loss may be inevitable, and the patient should be kept comfortable and offered nourishment even if it is refused. It is important to note that even with a tube feeding, weight loss may occur due to stress-induced hypermetabolism and/or catabolism.

Conclusion

       I often hear from at-risk residents, “I just don’t have any appetite.” While I wonder what that must be like, I know that coaxing them to eat will not solve the weight loss puzzle. Instead, knowing residents’ habits and evaluating each person individually will help find the solution to unintended weight loss that will work best for them.