Unwanted Weight Gain in Aged Care Facilities

While most of the referrals for dietitian input in aged care facilities relates to unwanted weight loss, dietitians can be asked for input with residents who have unwanted weight gain.

What is overweight?

For many adults we use the Body Mass Index as a basis for identifying a ‘healthy weight range’.  The BMI is a ration of the person’s height to their weight.  (kg/m²)  The BMI is not without its limitations, but generally it is a useful tool in assessing if someone is within the recommended weight range (BMI 20 – 25kg/m²), below it (underweight and malnourished) or above it (overweight and obese).  For older adults, the ‘healthy weight range’ tends to shift upwards.  There is evidence older adults with a BMI between 22 – 27 kg/m², have a longer life expectancy.  There is evidence that older adults who have unwanted weight loss will reduce their life expectancy.

What is the aim?

The first question to ask is whether this weight gain is a cause for health concern, and if there are benefits gained from weight loss.  In some cases weight gain may lead to reduced mobility, worsening blood sugar control, exacerbation of shortness of breath and gastric reflux, problems in fitting clothes, problems with ill-fitting hoists, chairs, and increased difficulty with transfers.  If it agreed that weight loss would be beneficial, the first nutritional goal is to prevent further weight gain.  Aim to stabilise the current weight.  Weight loss may be the next goal once weight stabilisation is achieved.

How much weight to lose?

Stabilising the current weight is a good start.  If weight loss is desired, set a realistic weight goal with the resident.  Health benefits are noticeable with as little as 5% weight loss.  A 85kg woman losing around 4kg should notice some benefits.

The goal of weight loss it to be losing body fat, not body muscle.  If weight loss is too rapid, the risk is that significant muscle mass is lost.  This can lead to worse health outcomes.

Involving the resident who has unwanted weight gain

A discussion with the resident about whether they are noticing any effects from the weight gain, and whether they would like to try and prevent gaining more weight, is essential.  It may be useful to explain the expected health benefits possible with weight loss. Family may also like to be consulted, but the decision and the motivation really needs to come from the resident.

Just telling a resident they need to lose weight, or automatically changing their diet is not treating a resident with respect, nor providing care that is tailored to their needs.  You may feel that the ‘best’ option would be to lose weight. The resident may feel different. They have the right to choose what’s right for them.

What strategies may help unwanted weight gain?

Losing weight is hard.  There needs to be a reduction in the energy intake with an increase in energy output.  Changes to food and changes to levels of activity are needed for optimal results.  Activity and body movement are important in helping to maintain muscle mass.  The diet still needs to remain nutritionally adequate, especially in terms of protein to minimise the loss of body protein too.  Continue to offer quality protein foods, at main meals and tea meals.

An aged care facility menu is nutritionally balanced and tailored to ensure the nutritional needs of the residents are met.  Talk with the resident about what ideas they might be happy to try to help reduce their food intake.  Small changes eventually add up to significant calorie reduction.  Start with changing one or two things only in the diet.  If that is successful, add in other small changes.

Reducing Food Intake

  • Target between meal snacks such as morning tea, and/or afternoon tea. If the resident is not hungry at these times, he or she may be able to skip the food offered
  • Limit sweet drinks; offer water, ‘diet’ options and a sugar replacement in hot drinks
  • Reduce the frequency of desserts in the week, or offer lower calorie options such as fresh fruit, diet jelly, low fat yoghurt. Limit the use of cream on desserts.
  • Ensure the size of the main meal is a medium meal (not large), serve extra vegetables if the resident is wanting more food.
  • Look at the quantity of food eaten at meals. Reducing the amount slightly can help.
  • Target the amount eaten at ‘happy hours’ and other treat times
  • Try to encourage the resident to limit the amount of extra foods they may be buying and having in their room
  • Ask family and friends not to bring in food items. Suggest other options such as magazines, books, photo albums, flowers

Increasing activity levels

  • Encourage the resident to join in the home’s activities
  • Encourage the resident to walk more if possible, around the home, to the dining room, around the garden – short distances at first so they gain a sense of achievement
  • Family and friends may be able to help by joining the resident in walks or taking them on outings too

These are some ideas to try.  For more information and tailored nutritional advice contact your clinical dietitian.  If the resident is ready to make some changes, offer support and encouragement, to help enable their success.  Be positive.  As with all of us, sometimes we deviate from our own ‘diet’; we have a treat or a dessert or a second helping.  Don’t judge residents, or be so strict with restricting foods.  Avoid using phrases that suggest the resident is ‘being good’ or ‘being naughty’ in terms of whether they are following the agreed diet plan.  There are no ‘good’ foods and ‘bad’ foods.  And finally, weight loss takes time.  Simply stalling the weight increase is a significant achievement.  Long term encouragement and support is essential for successful and sustained weight loss.

Article contributed by: Liz Beaglehole (NZ Registered Dietitian), Canterbury Dietitians

liz@canterburydietitians.co.nz

Using physiotherapy assistants in residential care

 

Employing a physiotherapy assistant (PTA) is a fantastic and cost effective way to implement physiotherapy programmes. Many residential care facilities contract in physiotherapy services at an hourly rate, often for only a few hours per week. Supporting this service by having an employee who can accompany the physio on their visit, and then put the exercise programmes in place supports real outcomes for residents.  When I quote for services to residential care facilities I always put a persuasive argument in place for them to appoint a PTA at the same time.

Of concern is that we sometimes visit facilities who have a physiotherapy assistant employed but no contracted physiotherapy hours. Why is this a problem and what are the consequences? The problem lies with the fact that “Physiotherapist” is a legally protected title and to practice in New Zealand you must be registered and hold a practising certificate. If there is any perception that the person is a physiotherapist or is carrying out ‘physiotherapy’ then this is illegal and the fine can be up to $10 000. The key word here is perception. Below are some examples that I have come across where I believe the work was illegal.

– A GP requested a physio assessment of a resident with a sore shoulder. This assessment was carried out by an overseas qualified   physio working as a PTA in a facility;

– A PTA doing exercises with a resident and the family said “she is having her physiotherapy session so we will wait”;

– Staff referring to their physiotherapy assistant as the “physiotherapist” in conversations.

Physiotherapy New Zealand has written guidelines for using a physiotherapy assistant (this covers the term rehab assistant also). The guidelines state that a client must have:

– An assessment by a NZ registered Physiotherapist and a treatment plan;

– Ongoing monitoring of the physiotherapy status and needs of the client.

The physiotherapy assistant must have strict boundaries which include being deemed competent by a supervising physiotherapist, not advancing or changing the treatment plan without written and verbal instruction from the physiotherapist, not offering any advice or opinion (other than reiterating the physiotherapist’s advice). They must have a clear written job description and adequate support. The work they carry out is the responsibility of the supervising physiotherapist which means only the physiotherapist can prescribe treatments which they have observed the physiotherapy assistant. Competency must be confirmed in respect of each individual treatment plan. This even includes simple exercises such as a walking programme.

We also recommend to our facilities that they consider getting a uniform that clearly designates the person as a ‘physiotherapy assistant’ and a name badge with this written. This helps greatly with the problem of other peoples ‘perception’ as already mentioned. We also recommend and provide separate documentation forms for PTAs.

Being a physiotherapy assistant is usually a very rewarding job but can be isolating for staff as they are usually the only one in their facility and often also have hours as a carer. It is good practice to support them with ongoing training and regular supervision with a physiotherapist that is not just focussed on their clinical role.

On the Go Physio offer regular training for physiotherapy assistants including a full day conference later in 2017. To find out more about the pending conference go here and request details.

This article kindly contributed by Jessie Snowdon – Physiotherapist,  founder and director of On the Go Physio. She graduated from Otago University in 1998 and has worked in Christchurch, Edinburgh and London in a variety of roles

Policies and Procedures folders

Policies & Procedures

Policy No. Titles for residential care service policies and procedures
CSM Care Services Manual introduction page
CS1 Admission to hospital for medical emergency
CS2 Adverse Health Policy
CS3 Anti-coagulation monitor
CS4 Warfarin blood monitoring results
CS5
CS6 Bereavement / Termination Care policy
CS6 A Bereavement notification form (and resource material)
CS7 Blood Glucose monitor form
CS7 A Blood sugar levels record sheet
CS7 B Diabetes Testing and Treatment sheet
CS7 C Blood glucose monitor form
CS8 Blood sugar equipment check
CS9 Blood sugar testing
CS10 Case Conference for care plan review forms
CS11 Care Plan Review Schedule
CS11 A Doctors Visits Schedule
CS12 Catheter management policy
CS12 A Catheter change schedule
CS13 Continence management policy
CS13 A Continence assessment form
CS13 B Continence Voiding Chart and Bowel chart
CS14 Clinical Management Policy (includes resource directly and key responsibilities)
CS14 A Robinson’s Resident Acuity & Clinical Risk Assessment
CS15 Challenging behavior assessment form
CS15 A Behavior monitoring chart
CS15 B Challenging behavior assessment form
CS16 Diversional Therapy – Quality of life policy
CS16 A Diversional Therapy – Residential profile
CS16 B Diversional Therapy – Care plan
CS16 C Diversional Therapy – Activities attendance register
CS16 D Diversional Therapy – Care plan evaluation form
CS16 E Sample Activities Calendar
CS17
CS18
CS19 Falls Prevention Programme
CS19 A Falls Risk Assessment – Coombe’s Assessment Form
CS19 B Repeated Falls Analysis – Accident Summary
CS19 C Resident Mobility Assessment Chart
CS19 D Resident Mobility Guide Form
CS19 E Post Falls Investigation Form
CS20 Fluid Balance Chart
CS20 A Daily Fluid Balance Chart (more reflective of hospital level care)
CS21 Handover sheet
CS22 Health status and clinical risk assessment policy
CS22 A Health status and clinical risk assessment form
CS23 ‘Health Promotion’ Initiative Planner
CS24 Lab form – Pathology report storage sheet
CS25
CS26 Long Term Care Plan (Including InterRai prompts and Evaluations)
CS26 A Short term care plan for acute issues
CS26 B Treatment Sheet
CS26 C Daily Care Summary (for inside wardrobe reference in resident room)
CS27 Care Plan multi-disciplinary review policy (and associated form)
CS28 Administration of medication policy – different version supplies for those using Medimap / 1 Chart
CS28 A Administration of medication procedure – different version supplies for those using Medimap / 1 Chart
CS28 B Glucagon Administration
CS28 C Blister pack contents verification
CS28 D Medication competency assessment forms
CS28 E Insulin competency assessment form
CS28 F Medication changes / order notification
CS28 G Medication order sheet – supplied for non-electronic system users
CS28 H Medication Signing sheet – supplied for non-electronic system users
CS28 I PRN medication signing sheet – supplied for non-electronic system users
CS28 J Medication error analysis form
CS28 K  Medication error analysis form
CS28 L  Respite / short term resident medication signing
CS28 M  Self Medication resident initial competency reviews
CS28 N  Self medicating – shift by shift verification
CS28 O Medication Returned to Pharmacy form
CS28 P Medication Key Holder Register
CS28 Q Injection Register form
CS30 Nebulizer usage and maintenance policy
CS31 Neurological Recordings policy
CS31 A Neurological Observation sheet
CS32 Podiatrist Service agreement
CS33 Pain Management policy
CS33 A Pain – Detailed Assessment form
CS33 B Pain – Review Assessment form
CS33 C Pain – ABBEY pain scale (for non-verbal resident)
CS33 D Pain – ABBEY pain scale reviews form
CS34 Personal hygiene and grooming policy
CS35 Pharmacy Service Agreement
CS36 Temp, Pulse and Respirations monitor form
CS36 A General Recordings record (optional use)
CS36 B Weight and Blood Pressure Monitor form
CS36 C Blood Pressure Monitor form
CS37 Pressure Injury Risk policy
CS37 A Pressure Injury Clinical Procedures
CS37 B Pressure Injury risk assessment form
CS38 Nursing (care) progress notes form
CS38 A Pressure Note Writing Guidelines
CS39 Medical Notes progress forms
CS40 Restraint / Enabler use policy and procedure
CS40 A Restraint / Enabler Authorisation form
CS40 B Restraint / Enabler Monitoring record
CS40 C Restraint / Enabler Register
CS40 D Restraint / Enabler Assessment prior to use
CS40 E Restraint / Enabler monitoring guidelines
CS40 F Restraint Approval Group Review meeting
CS40 G Restraint / Enabler Review form
CS41 RN – Medical practitioner communication
CS42 Sleep and Comfort policy
CS42 A Sleep Monitor form
CS43 Turn Chart for bed-ridden resident
CS44 Weight Management policy
CS44 A Weight Monitoring chart
CS45 Wound Management policy
CS45 A Wound care plan / dressing schedule
CS45 B Wound care competency assessment
Policy No. Title for residential care food services policies and procedures
FSM Food Services Manual introduction page
FS1 Admission Food & Nutrition Information
FS1 A Breakfast Order forms
FS2 Food brought into the facility
FS3 Food Safety policy
FS4 Food Services for the Elderly
FS4 A Food & Nutrition guidelines for the older person
FS4 B General tips for helping older persons eat etc.
FS4 C Ageing Process and Care Provisions Issues
FS4 D Eating Difficulties – Dry or Sore Mouth
FS4 E Fluids – Preventing Constipation
FS4 F Food and Medication Interactions
FS4 G Vitamin and Mineral Supplements
FS5 Food Services Questionnaire for Residents
FS6 Safety Checklist for Kitchen Services Areas
FS7
FS7 A Sample Menu – Winter 1
FS7 B Sample Menu – Winter 2
FS7 C Sample Menu – Winter 3
FS8 Microbiological Data Sheets – food Safety
FS9 Food services ordering and monitoring
FS10 Food services preferred suppliers
FS11 Food/fluid Intake Chart
FS12 Resident Food / Fluids Preferences at a glance form
FS13 Food Services Staff Responsibilities
FS14 Food Storage Policy
FS15 Food Thawing Policy
FS16 Meal Service Policy
FS16 A Resident Meal Receipt Verification Form
Policy No. Policy Title for Residential Care Service Delivery policies and procedures
SD1 Acquisitions Order Form
SD2 Common Abbreviations
SD3 Communication Policy
SD3 A   –  Sensory Communication Policy
SD4 Clinical documentation and report writing policy
SD5 Day Care Policy
SD5A Day Care – Client Care Plan
SD6 Family / Whanau / Resident Representative Contact sheet
SD7 Reassessment Referral Policy
SD8 Resident Inquiry for Admission Form
SD8 A Resident Inquiry for Admission Form (alternative form)
SD9 Resident Medical File Checklist
SD10 Transfer / Discharge of Residents Policy
SD10 A Transfer / Discharge Form
SD11 Medical Services Contract
SD12 Authorised Signatures register
SD13 Change of Resident Status Notification
SD14 Internal Telephone Numbers Listing

Falls – When is a fall not a fall?

Is a slip off a chair or off the side of the bed onto the floor a fall?  Is a ‘controlled lowering’ by a staff member of a resident to the floor a fall?

When recording adverse events such as falls, it’s important for the purposes of consistent reporting and bench-marking that the same definition is used to define a ‘fall’.  We suggest using the definition provided by the World Health Organisation (WHO) which states “A fall is defined as an event which results in a person coming to rest inadvertently on the ground or floor or other lower level.”  The WHO falls prevention guidelines also report that “Globally, falls are a major public health problem. An estimated 424 000 fatal falls occur each year, making it the second leading cause of unintentional injury death, after road traffic injuries.”  

Working in aged care related services means you are interacting on a daily basis with those in the high risk category for falls. WHO also report for example, in the United States of America, 20–30% of older people who fall suffer moderate to severe injuries such as bruises, hip fractures, or head traumas. The Health Quality and Safety Commission New Zealand reportfor every fall in hospital, there are five in aged residential care and another 40 at home and in the community. Between 2010 and 2012, a total of 200 people fell while in hospital care and broke their hips.

The HCSL QA online bench-marking includes tracking of falls and falls related injuries so educating your staff to become familiar with the definition is important in ensuring data collected is accurate. Accurate data measurements also allow you to be aware of your start point for quality improvement projects which can then be measured at the end of a project to measure the degree of improvement.

In answer to the questions posed at the start of this article, if we apply the WHO definition, then both should be classified as falls.  For those of you using the HCSL policy and procedure system, refer to the Falls Prevention Programme (document CS19) for more information on falls prevention.

Pressure Injuries – ACC may be able to help

‘Pressure injury’ according to ACC can be classified in some instances as a ‘treatment related injury’ and therefore you may have the option of gaining support / assistance from ACC in relation to treatment of the pressure injury. In their 2011 fact-sheet, ACC noted “Pressure areas are a significant source of treatment injury claims and impact on both patient morbidity and mortality (1). Between July 2005 and March 2011, ACC accepted 506 claims for pressure areas, and notified 45 as adverse events to the Ministry of Health”.

As pressure injuries are a key focus for Ministry of Health (MoH) this year, auditors will be looking closely at the documentation around identification, management, treatment / care planning and evaluation of these events. Ensure you have comprehensive evidence of your clinical management processes.

Also remember when you log a pressure injury into the adverse event reporting system, you include the stage of the pressure injury. In the HCSL QA online system click ‘pressure injury’ in the ‘type of event’ box and then in the box directly under that, you can record the additional detail of the stage of the pressure injury.

The required MoH notification forms can be found here.  You will need the resident GP to complete a ACC45 form. Then contact ACC and rather than asking for what you want, ask what they can do to help. If you ask first, you may be missing out on something they could have provided access to.

For more information on seeking support contact Assistant ACC directly or the ACC Contracts Manager – CDHB Email: Leanne.davie@cdhb.health.nz