Unintentional weight loss
A very common adverse clinical outcome for residents is unintentional weight loss. It can contribute to a decline in general health, energy, about to heal in relation to skin / wound care and increase the risk of accidents.
Ensuring adequate nutritional intake relevant to the health status for each resident is ultimately the responsibility of Registered Nurses. There has been the perception in some instances that it’s normal to lose weight as people age. While there is an increased tendency to lose weight, it should not be considered normal.
If unintentional weight loss is detected, ensure thorough multi-disciplinary clinical assessment and development of specific short term care plan to define strategies to meet the specified care plan goal. Offering more frequent high energy (high calorie) and high protein snacks and drinks between main meals and instigating the recording of all food and fluid intake should be part of this plan (unless contraindicated). The dietitian can best help guide you through the best nutritional support for each individual resident and their circumstances at the time.
Unintentional weight loss or the undesirable decline in total body weight over a specified period of time is common however should not be ignored as ‘part of ageing’. Sarcopenia (muscle loss in the elderly) is also common however not inevitable and should be addressed through a targeted exercise and balance programme. Light body weight in the elderly have been shown to have a detrimental effect on the resident ability to function and on their general quality of life.
Unintentional weight loss of 3 -5 percent (or greater) in 30 days (or 10 percent in 180 days) must be monitored more closely and a short term care plan must be developed to promote weight loss cessation and implementation of weight management practices. RN’s must ensure they review regular weight monitoring records to identify progressive changes and respond to adverse patterns.
Residents that have been determined to be in later stages of palliative care or receiving terminal cares should be excluded from the need for close monitoring and related care planning related to trying to reverse unintentional weight loss. This is at the discretion of the Registered Nurse in consultation with the Doctor and next-of-kin / advocate / whanau. Discussions will also be had with the resident and the Medical Practitioner regarding the extent or type of tests, investigations and interventions that are desirable. These must be clearly documented in the Care plan evaluation and interventions recorded in the long term care plan and Doctors consultation notes.
Ensure the specific instructions (interventions) are recorded in the care plan for staff to implement on a consistent basis. Ensure these are reviewed at each weight monitoring event (time-frame specified in care plan) and adjust interventions according to weight monitoring outcomes.
If after two weeks of weekly monitoring the weight has not stabilized or started to increase, consult a Dietitian to review the resident and provide recommendations. Ensure any recommendations are followed as directed.
Treat any underlying cause and continue monitoring of weight until it has reached optimum levels in accordance with care plan goals. Return to monthly monitoring of weight at this stage. Those on special diets must be monitored more closely than those residents that are independent with eating and drinking or those that have no identified difficulties which may lead to increased potential for unintentional weight loss.
An 84 year old female resident (Mrs A) with a diagnosis of chronic heart failure and early dementia was noted to be experiencing progressive weight loss. Staff indicated she was able to physically feed herself but often refused to eat, pushing the meal tray away from her. She was able to express her needs to the extent of saying she didn’t want her meal. Staff recorded this in the progress notes however no investigation was done to identify the cause of her refusal to eat. Her weight had reduced at that point to 38kg having had an admission weight of 48kg only six months previously. Staff noted Mrs A was often sleepy during the day and expressed their belief her dementia was advancing. A new Clinical Nurse Lead (CNL) sat down and talked with Mrs A to discover that her mouth wasn’t sore and her dentures were well fitting. There appeared to be no difficulty with her ability to eat or swallow. The CNL consulted with the dietitian to support the assessment process. It was decided that a staff member would sit with Mrs A and gently talk with her as the staff member offered small spoonfuls of food. Mrs A obliged with eating with no resistance or protest and seemed to enjoy her meal. Progressively day after day her intake increased and she seemed to be sleeping less. She had more energy and within a period of one week had shown an 800 gram weight gain. Staff continued with supporting Mrs A with assisting her with her meal and within 6 weeks her weight had increased from 38kg to 41kg. At that time she was no longer sleeping most of the day and had resumed feeding herself. Short term care plans were instigated at the start of this process and more detailed long term care planning and regular assessment was also documented. Family input had been sought to gain a greater understanding of Mrs A’s previous eating patterns and she was able to talk about the foods she enjoyed having with her family. Asking questions about a context such as family meals assisted the staff in gaining more information than if they’d simply asked Mrs A what her favourite foods were. Giving a direct answer to a specific question wasn’t easy for Mrs A however she was able to talk about family meal times which proved a valuable source of information for nursing staff in supporting her. At the end of an 8 week period Mrs A had more energy, was interacting more with others, was sleeping less during the day,appeared happier and was enjoying her meals. She was no longer refusing to eat. It stands to reason that when a person is lacking nutrients, they may actually lose the energy needed to feed themselves. Getting the basics right is a good place to start.