Jun 28, 2017
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Preventing Weight Loss in the Elderly

In the healthcare setting, we see the following scenarios nearly every day. An elderly male is admitted for therapy after hospitalization for CHF (Congestive Heart Failure) exacerbation; he’s still grieving the passing of his wife and finds himself eating more TV dinners alone. A frail elderly female is no longer able to care for herself at home due to dementia, falls, weakness, and recurring urinary tract infections; she’s started to become incontinent and is afraid to drink much fluid for fear that she’ll have an accident. Many factors can put the elderly population at increased nutritional risk.

Diminished sense of smell, taste and thirst, decreased appetite, and early satiety (fullness) are associated with the physiological process of aging.1 Altered dietary habits, acute and chronic health conditions, functional decline, limited mobility, and medication issues can put older adults at greater risk for unintentional weight loss (UWL).2 UWL in older adults is associated malnutrition, frailty, hospital readmission, falls, morbidity and mortality.2,3 Timely identification of those at risk, evaluation by a registered dietitian, early intervention and monitoring may help prevent weight loss and improve outcomes.3

The Academy of Nutrition and Dietetics (AND) recommends use of nutrition screening instruments validated for older adults, including The Mini Nutritional Assessment Short Form and the Nutrition Screening Initiative DETERMINE Your Nutritional Health (DETERMINE)3. Refer individuals at increased risk to a dietitian for evaluation; full nutritional assessment should include risk factors for potential weight loss3. The mnemonic “Meals on Wheels” listed below summarizes common treatable causes of unintentional weight loss in the elderly.4

Medication Effects. Many medications have side effects such as dry mouth, taste and smell changes, appetite changes, swallowing difficulties, nausea or vomiting, which can negatively affect oral intake. Polypharmacy (use of multiple medications) may increase risk of negative side effects. Dietitians should review medications for risk of weight change may refer to the physician for evaluation of medications and adjustment as necessary.

Emotional Problems. Underlying dementia, general anxiety disorder, or personality disorders may negatively impact desire to eat. Monitor for signs and symptoms. Consider referral to the residents’ physician for psychological evaluation if symptoms are suspected to be interfering with appetite/intake or noted to have recently increased in frequency or intensity.

Anorexia nervosa (AN), alcoholism. These conditions increase risk of undernutrition, malabsorption, and nutritional deficiencies.5 Residents with a history of poor intake or recent rapid weight loss may need to gradually increase nutrition intake to prevent refeeding syndrome.5 As intake increases, metabolic needs increase dramatically.5 Fortified foods, oral supplements, snacks, and vitamin/mineral supplements may help meet needs and prevent weight loss.

Late-life paranoia. This may be related to sensory impairment, depression, Alzheimer’s disease, mood disorders or other dementias.6 Past medical history and physical examination should be considered during nutritional assessment; dietitians may recommend checking serum folate and B12 labs if the individual is at risk for deficiency.6

Swallowing Disorders. Pocketing food in cheeks; coughing after swallowing; wet, gurgly voice after swallowing; food or fluid leaking from mouth; excessive time or effort needed to chew or swallow; recurring pneumonia; and/or inability to meet needs resulting in weight loss or dehydration may be signs of difficulty swallowing (dysphagia)7 and should warrant a referral to a speech therapist for further evaluation. If a resident requires an altered texture diet or thickened liquid consistency that they may dislike, it may put them at higher risk for unintentional weight loss and dehydration. Monitor for reduced intake and encourage as needed. Offer liquids throughout the day; consider offering appropriately thickened supplements; or offer preferred foods (i.e. ice cream with meals for puree diet with thin liquids or pudding between meals for those requiring honey-thick liquids).

Oral factors (e.g., poorly fitting dentures, caries). Missing teeth, poorly fitting dentures (not uncommon after weight changes), and painful dental caries can lead to weight loss if not caught early. Upon admission to a facility, check dental status. Monitor at meals for any wincing, excessive chewing, or visible movement of dentures. For residents able to communicate, ask if they are having any pain or difficulty chewing. Promptly follow-up with family regarding appropriate dental appointments and consider modification of diet texture to accommodate needs.

No money. In the community setting, poverty can have a detrimental effect on nutritional status. Work with social services to connect elderly persons with appropriate programs such as Meals on Wheels, Elderly Nutrition Program, SNAP, and/or local food pantries. In an institutional setting, residents may refuse to eat or leave dining room due to concern over payment of the meal. If a resident refuses to eat or leaves the dining room before eating, ask why. Due to dementia or habit, they may respond that they didn’t or can’t pay for the meal. A smile and reassuring response such as “it’s already been taken care of,” “your family has paid for your meals,” or “it’s on the house!” may be all it takes to alleviate the residents concern and allow them to eat comfortably.

Wandering and other dementia-related behaviors. Continuous physical activity such as walking can increase metabolic needs. Other behaviors such as playing with food, resisting care, short attention span, and sleeping during meals can make it difficult for residents to meet nutritional needs. Consult with a dietitian for evaluation of energy needs and appropriate interventions; be sure to report any symptoms observed. If a resident is sleeping or lethargic at meals, report symptoms to the doctor and consult for review of medications. If weight loss has occurred or is anticipated, interventions may include encouraged consumption of high calorie foods and beverages; snacks made available between meals; altered texture, or adaptive equipment. Interventions may need to be adjusted as behaviors change; don’t be afraid to get creative and try something new!

Hyperthyroidism, hypothyroidism, hyperparathyroidism, hypoadrenalism. Physiological effects of these conditions may alter metabolism and medications may alter appetite and intake. Consult a dietitian for review of needs.

Enteric problems (e.g. malabsorption). Several conditions, including Celiac disease, Whipple disease, Crohn’s disease may cause malabsorption. Physiological changes with age may increase risk of reduced absorption of calcium, zinc, and magnesium; reduced production of stomach acid (achlorhydria) associated with age may impair absorption of vitamin B12, folic acid, and calcium. Monitor for symptoms of diarrhea, steatorrhea, weight loss and fatigue, flatulence and abdominal distention, edema, and anemia; bleeding disorders, metabolic defects of bones (osteopenia or osteomalacia), and neurolic manifestations, which may be related to nutritional deficiencies.8 Physically examine for visible signs and symptoms of nutritional deficiency and refer to a dietitian for full evaluation. 

Eating problems (e.g., inability to feed self). Studies have shown dependence on others for feeding increases risk of poor nutritional status and weight loss.3 Maintaining independence as long as possible through use of adaptive equipment, finger foods, bowls, and cups with lids and/or straws may improve oral intake. Invite family members to come for meals and assist if possible. Provide training to staff on proper feeding techniques and ensure that those requiring assistance are assisted in a timely manner.

Low-salt, low-cholesterol diet. A cardiac diet can be bland and may not appeal to an older adult with diminishing appetite and reduced taste sensation. These diets are lower in fat and often lower in calories; the decreased calories alone may promote weight loss and if the resident is eating less due to dislike, even fewer calories may be consumed. Use of diets restricting sodium, fat, carbohydrates, and cholesterol has not been shown by research to benefit elderly adults.3 Liberalization of diets or elderly adults may help improve oral intake.

(Gall) Stones, social problems (e.g., isolation, inability to obtain preferred foods). Gallstones can be incredibly painful and may lead to pancreatitis, which could require nutrition support; small, frequent meals and a low-fat modest protein diet may improve symptoms until stones can be removed.9 Include residents in menu planning; this may help improve oral food and fluid intake.3 Encourage residents to come to the dining room for meals; research indicates that older adults may have improved intake when eating in a socially stimulating dining area.3

Early identification of individuals at risk for malnutrition; prompt referral for dietitian evaluation; and multidisciplinary implementation of interventions to address treatable causes of weight loss may help prevent negative complications associated with unintended weight loss. As they say, “it takes a village.” Let’s work together to keep our elderly residents hearty, healthy, and happy!

 

References

  1. Stajkovic, S, Aitken, EM, Holroyd-Leduc, J. Unintentional weight loss in older adults. 2011; 183(4): 443-449. Doi: 10.1503/cmaj.101471.
  2. DiMaria-Ghalili, RA. Integrating Nutrition in the Comprehensive Geriatric Assessment. Nutr Clin Pract. 2014;29(4): 420-427.
  3. Unintended Weight Loss in Older Adults Guideline. Academy of Nutrition and Dietetics Evidence Analysis Library. http://www.andeal.org/topic.cfm?menu=5294&cat=3652. Published 2009. Accessed March 2015.
  4. Huffman, GB. Evaluating and treating unintentional weight loss in the elderly. Am Fam Physician. 2002; 65(4):640-651.
  5. Waterhous, T, Jacob, MA. Practice Paper of the American Dietetic Association: Nutrition intervention in the treatment of eating disorders. American Dietetic Association. 2011;111(8) 1236-1241.
  6. Chaudhary, MA, Rabheru, K. Paranoid Symptoms Among Older Adults. Geriatrics and Aging. 2008;11(3):143-149.
  7. American Speech-Language-Hearing Association Staff. Swallowing Disorders (Dysphagia) in Adults. American Speech-Language-Hearing Association. http://www.asha.org/public/speech/swallowing/Swallowing-Disorders-in-Adults/. Accessed March 2015.
  8. Goebel, SU, Katz, J ed. Malabsorption. http://emedicine.medscape.com/article/180785-clinical. Updated December 2014. Accessed March 2015.
  9. Academy of Nutrition and Dietetics Staff. Gallbladder Nutrition Care. Nutrition Care Manual. https://www.nutritioncaremanual.org/topic.cfm?ncm_category_id=1&lv1=5522&lv2=145224&ncm_toc_id=18679&ncm_heading=Nutrition%20Care. Accessed March 2015.

Comments

  1. paul dave says:

    Great article. Thanks for the info, you made it easy to understand. BTW, if anyone needs to fill out a “Nestle Mini Nutritional Assessment”, I found a blank fillable form here:mini assessment. I also saw some decent tutorials on how to fill it out.

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