Journal of Gerontological Nursing

DETECTION AND CORRECTION of Underweight Problems in Nursing Home Residents

Ruth Gants, RN, BA

Abstract

ABSTRACT

Subnormal weight in the elderly is a well-known phenomenon; the ramifications may result in illness and death. There are many reasons for weight loss, usually related to changes that accompany aging or against a background of acute or chronic illness.

Our goal in this study was to identify the underweight people living in our retirement facility at different functional levels and to plan and carry out nursing interventions in cooperation with the rest of the multidisciplinary team to increase their weight to within normal limits.

Of the 205 residents who live in the home, 48 (23.4%) were found to be under the lower limit of ideal weight tables. With the aid of individual care plans and calorie-rich, low-volume diets, we succeeded in increasing the weight of 29 residents to within the normal range within 2 to 12 months. Seven residents died during the experimental period, and three continuing to lose weight. The rest of the residents remained stable at their original low weight.

Abstract

ABSTRACT

Subnormal weight in the elderly is a well-known phenomenon; the ramifications may result in illness and death. There are many reasons for weight loss, usually related to changes that accompany aging or against a background of acute or chronic illness.

Our goal in this study was to identify the underweight people living in our retirement facility at different functional levels and to plan and carry out nursing interventions in cooperation with the rest of the multidisciplinary team to increase their weight to within normal limits.

Of the 205 residents who live in the home, 48 (23.4%) were found to be under the lower limit of ideal weight tables. With the aid of individual care plans and calorie-rich, low-volume diets, we succeeded in increasing the weight of 29 residents to within the normal range within 2 to 12 months. Seven residents died during the experimental period, and three continuing to lose weight. The rest of the residents remained stable at their original low weight.

Weight loss among the elderly, while coramon, has not been given proper scientific attention. Although the gradual weight loss that begins in middle age may reflect normal aging of lean body mass, weight loss at an advanced age becomes a risk factor causing morbidity and mortality (Robbins, 1989; Silver, Morley, Strome, Jones, & Vickers, 1988). Compared with other elderly patients, those who weigh 20% below average tend to suffer more from anemia (57% vs. 28%), hip fractures (57% vs. 15%), decubitus (43% vs. 21%), dementia (43% vs. 18%), hypothyroidism (29% vs. 5%), cancer (14% vs. 3%), and depression (14% vs. 10%) (Silver, et al., 1988).

Russell, Sahyoon, and Whinston-Perry (1986) studied the nutritional status of elderly patients hospitalized in several acute settings. The estimated frequency of underweight individuals ranges from 17% to 65% of the patients, with the largest numbers found among nursing home residents.

Pinchovsky-Devin and Kaminski (1986) assessed the nutritional status of older adults in two metropolitan nursing homes. They suggested an extremely high degree of malnutrition in this group. Robbins (1989) mentions that the nutritional status of the long-term institutionalized elderly has not been given proper attention and that few studies have examined the incidence, prevalence, and causes of weight loss occurring specifically in elderly patients.

CAUSES OF WEIGHT LOSS

Over 50 factors are mentioned by Olsen-Noll and Bosworth (1989) that may lead to anorexia (loss of appetite) and weight loss in the elderly. These factors include: gastrointestinal disorders; metabolic disorders; toxic or pyrexial illness; cardiopulmonary disease; drug toxicity; neoplasms; nutritional problems; perceptual and social problems; and behavioral and psychiatric disorders. Robbins (1989) summarizes the above factors as the "nine Ds": Dementia, Dentition, Depression, Diarrhea, Dysphagia, Dysguesia, Dysfunction, Drugs, and Disease (chronic).

Failure to thrive (FTT) is hazardous to the elderly. It is manifested by a gradual weight loss, sometimes culminating in death. The cause of FTT is not quite known; it may be connected with disguised depression, long-term isolation, or institutionalization. In general, FTT seems to appear as a result of loneliness and lack of attachment (Braun, Wynkle, & Cowling, 1988).

Table

TABLE 1Causes for Loss of Weight in Older Adults

TABLE 1

Causes for Loss of Weight in Older Adults

Palmer (1990) could not find any apparent reason for the 25% of underweight older adults in his study. Some claimed that they had "always been thin," and nurses reported that they indeed consumed sufficient quantities of food, but their weight remained low (Table 1).

Newbern (1992) raises the dilemma of which came first. Did disease cause weight loss or did loss of weight bring about illness and its symptoms? Miller (1990) cites a number of negative consequences of age-related changes that might be risk factors and influence nutrition and digestion.

As elderly people tend to suffer from a complexity of age-related changes and multiple pathologies, a direct cause of weight loss cannot be readily determined from among the multitude of potential causes. Despite this, medical history, functional and nutritional assessments, and drug regimes can suggest whether there is a risk factor for loss of weight. Laboratory results, such as low hemoglobin or low level of functional independence, may be predictors of weight loss complications.

METHOD

In the Sephardic Nursing Home in Haifa, Israel, there are 205 residents, between 56 and 95 years old. All participated in the program to detect and correct underweight individuals. According to functional ability, 22 of the residents were totally independent in activities of daily living (ADL), 77 needed some help in ADL, 73 were totally dependent, and 33 were in a special ward for Alzheimer's patients in early stages of the disease. The ideal weight range for each individual, calculated from the height, sex, and body structure (Metropolitan Life Foundation, 1983), was taken into consideration. The height of the totally dependent participants was calculated using the knee height procedure (Figure 1) (Chumlea, Roche, & Mukherjee, 1984).

Residents were weighed monthly, and their weight was compared to their ideal body weight range. Thus, we could assess whether residents were in their normal body weight range and whether they were losing weight, gaining weight, or remaining stable.

We located residents who weighed less than their ideal weight and divided them into two categories. In the first category were residents who were on a decline or weighed up to 20% less than their ideal weight range. They were defined as moderately underweight. In the second category were residents who weighed 20% or more less than their ideal weight range, and these were classified as severely underweight. These residents became the subjects of our nursing interventions.

While searching for potential causes of weight loss, an individual correction program was initiated. Nurses observed each of the underweight subjects for 3 to 5 days, monitoring their daily food intake. The nurses recorded which of the food items offered to them they actually ate or drank. This enabled the calculation of their real daily nutrient and caloric intake. With these parameters, the resident dietitian determined the proper diet, enriching it with food supplements to reach their appropriate daily recommended allowance of nutrients and calories (National Academy of Sciences/National Research Council, 1980). Table 2 describes the 10 steps of detection and correction procedures used.

Residents who had difficulty chewing or swallowing or those who were severely underweight, received additional supplements that offered high amounts of calories in a low volume of liquids, some enriched with vitamins and minerals and some with proteins. Among the supplements used were: Caloreen, Proform, Sustacal pudding, Ensure Plus, Biocare Shake, and Osmolite (Table 3). Nurses administered these products according to medicationadministrating protocols.

Underweight subjects were weighed once a week, and when they reached their ideal weight range, they were once again given a standard diet with ordinary food. A follow up was conducted once a month.

RESULTS

In November 1991, 205 residents of the Sephardic Nursing Home were weighed to identify underweight individuals. Forty-eight (23.4%) of the residents were found to weigh below their ideal weight range, 28 of whom were moderately underweight, and 20 of whom were severely underweight.

By differentiating the 48 underweight subjects according to functional level, it was found that 5 of them were independent, 14 needed some help for ADL (frail), 22 were totally dependent, and 7 were cognitively impaired due to Alzheimer's disease (Table 4).

All these subjects were monitored over a 1-year period, from November 1991 to November 1992. In November 1992, 21 of the 28 subjects in the moderately underweight group reached and maintained their ideal weight range. The other 7 subjects were still underweight but stable (Figure 2).

Six subjects in the severely underweight group died during the program. One had reached his ideal weight range, one was gaining weight, and one was stable; however, three continued to decline despite a high-calorie diet and supplements. The other 14 severely underweight subjects showed mixed results. One subject gained weight to 10% above the ideal weight range, three reached moderately underweight status, one was starting to gain weight, and nine were still severely underweight but stable.

Table

TABLE 2Steps Used to Detect and Correct Underweight Older Adults

TABLE 2

Steps Used to Detect and Correct Underweight Older Adults

CASE STUDY

A cognitively competent but physically totally dependent resident, who was found to be in his ideal weight range in November 1991, began to lose weight steadily, going from 62 kg in November to 48 kg in June of 1992. His ideal weight range, according to his height of 161 cm, was between 60.6 kg and 65.2 kg.

The reason for his weight loss was probably due to his emotional state of mind. He began to eat less food at each meal to the point of refusing to eat at all. Discussions with various staff members did not seem to help, and offering him his favorite foods did not tempt him to eat.

In June 1992, he began to receive food supplements, Ensure Plus and Caloreen, which we hoped would enable him to reach a daily calorie intake that would enable him to gain weight at a rate of about 2 kg a month. We treated these food supplements like medicine and regularly gave them to him between meals (at 10 a.m. and 4 p.m.). He slowly began to gain weight and, after 2 months on this regime, reached 52 kg.

With this weight gain, his appetite returned, and he began to eat larger portions of food at meal times. He also began to cooperate with the staff in the ward who were concerned about his weight. With the gain in weight came an increase in the resident's motivation, and it was deemed feasible to stop giving him food supplements as he renewed the intake of sufficient nutrients from the regular meals.

DISCUSSION AND RECOMMENDATIONS

Views differ regarding several substantive issues associated with the problem of weight loss in the elderly. One important question is: Should the ideal weight values determined for adults between 20 and 54 years old be valid for the elderly? It is well known that it is characteristic for the well elderly to lose weight in response to certain conditions, such as a slight rise in body temperature (which may be caused by an organic imbalance) or the influence of any psychological problem, causing loss of appetite and loss of weight followed by difficulty in recovering physically. Therefore, it has been recommended that the older adult should be about 5% above the ideal weight range.

Figure 2: Dynamics of the Number of the moderately underweight subjects.

Figure 2: Dynamics of the Number of the moderately underweight subjects.

Table

TABLE 3Composition of Food Supplements

TABLE 3

Composition of Food Supplements

Table

TABLE 4Classification of Underweight Sub jects According to ADL Level

TABLE 4

Classification of Underweight Sub jects According to ADL Level

Another question that arises in this context is: What is the ideal recommended daily calorie allowance suitable for the elderly? It is suggested that the retired elderly may not need the same amount of calories required by younger adults because they tend to pursue less physically active lifestyles. On the other hand, there is probably a decline in digestive and absorptive ability due to age-related causes, pathophysiological causes, or dietary restrictions.

These two problems emphasize the need for specific knowledge that gerontological nurses need to possess to deal with older adults. It is necessary not only to understand the characteristics of old age but to be sensitive to individual responses and address them accordingly, as in other periods of the life cycle, so people can grow, develop, and lead a naturally healthy life.

NURSING IMPLICATIONS

In light of this study, the body weight of older adults should be regularly checked and standardized by a nursing protocol, the same as other physical parameters such as blood pressure, pulse, and body tempera-* ture. Body weight should always correspond with an individual's ideal weight range values. Once a tendency to lose weight is noted, appropriate action should be initiated.

In long-term care facilities, a program of detecting and correcting weight loss is feasible because residents are monitored regularly. When a resident loses weight, sometimes in an obscure pattern, periodic weighing will detect it, and a correction program can be started immediately Severe weight loss should be carefully considered. It may occur when elderly patients suffer an acute attack of some disease or when hospitalized for surgery. A sharp decrease of more than 10% of ideal body weight may arrest the older adult's potential for recovery. It is advisable to bring the weight of residents to approximately 5% more than the ideal weight range, if possible, and to periodically monitor them.

Unintentional weight loss can be a risk factor for older adults who live alone, with family, or near family or other caregivers. The community health nurse has the responsibility of educating patients and caregivers on the importance of proper nutrition and weight monitoring on a regular basis. Elderly people who are at their correct weight and nutritional status are less vulnerable to diseases and other deteriorating states.

The issue, therefore, needs to be brought to the attention of older adults and their families. Patient education, including informative well-written pamphlets, should be developed to explain the benefits of maintaining correct body weight and nutrition and to suggest some guidelines for management when there is a risk for decline.

REFERENCES

  • Braun, J. V, Wynkle, M.H., & Cowling, W.R. (1988). Failure to thrive in older persons: A concept derived. Gerontologist, 28, 809-819.
  • Chumlea, W.C., Roche, A.F., Mukherjee, D. (1984). Nutritional assessment of the elderly through anthropometry. Columbus, OH: Ross Laboratories.
  • Metropolitan Life Insurance Company. (1983). Tables for body ideal weight range. Statistical Bulletin Metropolitan Life Insurance, 64(\).
  • Miller, CA. (1990). Nursing care of older adults. Glenview, IL. Scott Foresman.
  • National Academy of Sciences/National Research Council. (1980). Recommended dietary allowances (9th ed.). Washington, DC: Author.
  • Newbern, V.B. (1992). Failure to thrive. Journal of Gerontological Nursing, 18(S), 21-25.
  • Olsen-Noll, CG., & Bosworth, M.F. (1989). Anorexia and weight loss in the elderly. Postgraduate Medicine, &5(3), 140-144.
  • Palmer, R.M. (1990). Failure to thrive in the elderly: Diagnosis and management. Geriatrics, 4i(9), 47-55.
  • Pinchofsky-Devìn, G.D., & Kaminski. M. V. (1986). Correlation of pressure sores and nutritional status. Journal of the American Geriatrics Society, 34, 435.
  • Robbins, LJ. (1989). Evaluation of weight loss in the elderly. Geriatrics, 44(4), 31-34, 37.
  • Russell, R.M., Sahyoon, N.R., & Whinston-Perry R. (1986). Nutritional assessment in the practice of geriatrics (1st ed.). Philadelphia: Saunders.
  • Silver, AJ., Morley, J.E., Strome, L.S., Jones, D., & Vlckers, L. (1988). Nutritional status in an academic nursing home. Journal of the American Geriatrics Society, 36(6), 487-491.

TABLE 1

Causes for Loss of Weight in Older Adults

TABLE 2

Steps Used to Detect and Correct Underweight Older Adults

TABLE 3

Composition of Food Supplements

TABLE 4

Classification of Underweight Sub jects According to ADL Level

10.3928/0098-9134-19971201-08

Sign up to receive

Journal E-contents