Managing Acute Weight Loss

Presented By:Rebecca Berman RD, LD/NMorse Life Director of Clinical Nutritionrebeccab@morselife.org

Session Objectives

•Understand normal age-related changes•Know the importance of nutrition in older

adults•Recognizing and preventing acute weight

loss in long-term care facilities•Understand the importance of nutrition in

the QIS Survey

Normal Age-Related Changes

•Body Composition •Skeletal Changes•Sensory Changes•Chewing and Swallowing•Hormonal Changes•Decreased Cognition and Memory Loss

Normal Age-Related Changes•Decreased organ function•Development of chronic disease•Alterations in digestion, absorption,

metabolism and excretion •Decreased nutrient utilization•Decline or loss of appetite•Weight Loss

Nutritional Needs of Older Adults•Calories - Needs decreased•Protein - Needs slightly increased•Fluid - Needs unchanged •Fiber - 25-35g/day•Vitamins - B6, B12, C, D, Folic Acid•Minerals- Calcium and zinc•Chronic Diseases – modify diet as needed•Focus on nutrient dense foods•Consume a variety of foods

Nutrition in Long Term Care•Develop a Plan of Care

▫Evaluate▫Define and Implement Interventions▫Create Goals▫Monitor and Evaluate Interventions▫Revise Intervention as needed

•Focus on weight maintenance and UBW•Educate and communicate with residents

and their families•Interdisciplinary approach•Maximize quality of life

Significant Weight Loss

CMS Definition•≥ 5% in 30 days•≥ 7.5% in 90 days•≥ 10% in 180 days

•Avoidable vs. Unavoidable Weight Loss

MDS Definition•≥ 5% in 30 days•≥ 10% in 180 days

Avoidable Weight Loss – CMS Definition•Resident did not maintain an acceptable

nutritional status and the facility did not do one or more of the following: ▫Evaluate clinical conditions and nutrition risks▫Define and implement appropriate

interventions▫Create goals and recognized standards of

practice▫Monitor and evaluate impact of interventions▫Revise interventions as appropriate

Unavoidable Weight Loss – CMS Definition

•Resident did not maintain an acceptable nutritional status even though the facility did:▫Evaluate clinical status and nutritional risks▫Defined and implemented appropriate interventions▫Created goals and recognized standards of practice▫Monitored and evaluated impact of interventions▫Revised interventions as appropriate

•Desired or planned•Weight loss secondary to a terminal diagnosis

Assess Weight Loss and Nutrition Risks

•Oral Health•Sensory

Impairments•GI Abnormalities•Physical

Limitations•Cognitive Ability•Meds•Weight

Status/BMI•Appetite

•Depression•Social Support•Infections•Wounds•Pain•Diseases•Lab values•Advanced Age•Dining atmosphere

Dining Room Observation•Frequency of Meals•Assistance at Mealtime•Meal Service•Dignity and independence – adequate time to eat•Positioning•Dining Room Atmosphere - lighting, noise level, adequate ventilation, odors, temperature •Meal Substitutes – Choice•Furnishing and Space – table height•Food Quality – attractive meals•Liquids at Mealtimes

Weight Loss and Nutrition Interventions•Interventions progress from least

aggressive and costly to most aggressive and costly ▫Dining room atmosphere▫Nutrition education and counseling▫Food preferences▫Time of meals▫Flavor enhancement▫Portion modification▫Snacks▫Fortified foods▫Alter food texture

Weight Loss and Nutrition Interventions

•Nutritional Supplements•Appetite Stimulants•Enteral Nutrition•Hospice•Diet Liberalization

Diet Liberalization• Reducing dietary restrictions• Increases food choices • Improves appetite• Decrease risk of weight loss• Prevent weight loss

complications• Improves food enjoyment

and quality of life• American Dietetic

Association Position Paper• Culture Change and Choice

Interdisciplinary Approach•Nursing - dining assistance, information•Occupational Therapy - positioning, self-

feeding, adaptive equipment•Speech Therapy - food and fluid

consistency•Psychologist/Psychiatrist - Depression,

Anorexia•Social Services•MD/ ARNP - medication review•Resident, Family or Personal Aid

Monitor and Evaluate Interventions

•Weights•Meal and snack consumption•Supplement acceptance•Labs•Effects of interventions•Adjust plan of care and interventions as

needed

Terminal Diagnosis

•Hospice care•Keep resident comfortable•Focus on quality of life•Liberalize diet•Maximize enjoyment and minimize pain•Provide family support•Risks vs. benefits of artificial nutrition•Weight loss likely unavoidable

Risks of Artificial Nutrition•Advanced Directives•Does not always prolong life•GI pain and discomfort•Electrolyte and fluid imbalances•Restricts freedom•Psychological distress•Spiritual, religious, moral conflicts•Quality of Life

Weight Loss and QIS Survey

•Stage I - Admissions sample, Census sample, Resident and staff interviews, MDS, Resident Observations, Dining Room Observation

•Stage II – Specific Critical Element Pathway

•Increased risk for mortality, malnutrition, dehydration, falls, fractures, infections, pressure ulcers

•Weight Loss Protocol•Documentation

QIS Stage 1•Admissions Sample Record (30 charts)

▫Don’t complete if terminal dx. or in facility < 15 days

▫Weight at admission and 15, 30 and 60 days after admission

▫Resident on weight loss program•Census Sample (40 charts)

▫Don’t complete if terminal dx.▫Current weight and weight 30, 90 and 180

days ago▫Resident on planned weight loss program

QIS Survey- Stage 1• Family Interview

▫Does the facility honor resident’s preferences on what he/she eats or drinks?

• Resident Interview and Observation▫Do you receive the fluids you want between meals?▫Are you able to participate in making decisions

regarding food choices/ preferences?▫Does the food taste good and look appetizing?▫ Is the food served at the proper temperature?▫Does resident demonstrate physical signs of

dehydration (i.e. cracked lips and/or dry mouth)?• Staff Interview

▫ Is the resident receiving a nutritional supplement?• MDS Data – 6 month look back

QIS – Quality of Care Life Indicators

Quality of Care Life Indicator Data Source

Threshold

Resident not receiving a nutrition supplement & underweight

Chart, SI, MDS

> 15%

Resident has a feeding tube MDS > 16%

Resident with weight loss MDS > 13%

Resident with unplanned significant weight loss Chart, MDS > 12%

Resident with a feeding tube and significant weight loss

Chart, MDS > 1%

Unplanned weight loss of ≥ 5% within 60 days of admission

Chart, MDS > 21.7%

Resident does not have access to fluids RI > 1%

Resident show physical signs of dehydration RO > 1%

QIS Survey – Stage II• Specific Critical Element Pathway

▫Nutrition, Hydration and Tube Feeding Status• Investigate three residents• Process

▫Observation – care provided consistent with care plan

▫Resident/Representative Interview▫Staff interview▫Comprehensive Assessment Completed▫ Interdisciplinary Care Plan Developed▫Care and Services Meet Professional Standards▫Care plan revised as needed

Criteria for Compliance

•F321 and F322 – Naso-Gastric Tubes•F325 – Nutrition•F327 – Hydration•F328 – Parenteral and Enteral Fluids•F157 – Notification of Changes•F353 – Sufficient Staff•F385 – Physician Supervision•F501 – Medical Director

Resources Neidert K., & Doner B. (2004). Nutrition Care of the Older

Adult. 2nd ed. USA: ADA.

Mahan L., & Escott-Stump S. (2004). Krause’s Food, Nutrition, & Diet Therapy. 11th ed. Philadelphia: Saunders.

American Health Care Association. March 2009, from Centers for Medicare and Medicaid Services Web site: http://www.cms.hhs.gov Web site: http://www.ahca.org

Nursing Home Quality QIS Survey. 2007, Web site: http://www.nursinghomequality.com