Managing Acute Weight Loss

1. Managing Acute Weight Loss Presented By: Rebecca Berman RD, LD/N Morse Life Director of Clinical Nutrition rebeccab@morselife.org

2. 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

4. Normal Age-Related Changes • Body Composition • Skeletal Changes • Sensory Changes • Chewing and Swallowing • Hormonal Changes • Decreased Cognition and Memory Loss

5. 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

6. 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

7. 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

8. MDS Definition ≥ 5% in 30 days ≥ 10% in 180 days Significant Weight Loss CMSDefinition • ≥ 5% in 30 days • ≥ 7.5% in 90 days • ≥ 10% in 180 days • Avoidable vs. Unavoidable Weight Loss

9. 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

10. 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

11. 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

12. 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

13. 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

14. Weight Loss and Nutrition Interventions • Nutritional Supplements • Appetite Stimulants • Enteral Nutrition • Hospice • Diet Liberalization

15. 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

16. 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

17. Monitor and Evaluate Interventions • Weights • Meal and snack consumption • Supplement acceptance • Labs • Effects of interventions • Adjust plan of care and interventions as needed

18. 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

19. 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

20. 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

21. 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

22. 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

23. QIS – Quality of Care Life Indicators

24. 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

25. 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

26. 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