WEIGHT LOSS IN THE NURSING HOME
CLINICAL PRACTICE GUIDELINE

 

DISEASE RECOGNITION

  • Unintentional weight loss (Minimum Data Set: 5% in 30 days; 10% in 90 days)
  • Or resident leaves 25% or more of food uneaten at two thirds of meals over past 7 days
  • [DOH surveyors formula: % of body weight loss = (usual weight-actual weight loss/usual weight) X 100

 

CONTEXT // COMMUNICATION

All residents must be evaluated for weight loss with treatment given, when possible and accepted by resident or Health Care Agent, to promote weight gain, or prevent further loss. If the resident is moribund or refuses treatment, after the initial evaluation and documentation of reasons for weight loss and stated wishes, no treatment is required. The MD or NP should communicate with resident and/or Health Care Agent, regarding the expected risks and outcomes of both treatment and non-treatment, and the facility nurse should provide ongoing communication with the responsible party. 

 

ASSOCIATED RISKS

  • Physiological changes of aging causing anorexia [change in taste or smell]
  • Medications causing nausea, anorexia, dysgeusia or dysphagia especially: NSAIDs, opiates, SSRIs, Digoxin, Dilantin, Coumadin, Glucophage, Aricept, Fosamax, Trental, Norvasc, antibiotics, Premarin, Theophylline, Alendronate
  • Psychosocial: depression, agitation, paranoia, psychosis, intention, grief, isolation
  • Diseases: HF, cancer, COPD, DM, infection, alcoholism, TB, cholelithiasis, oral/esophageal candidiasis, thyroid, malabsorption syndromes, neurological disorders, dementia, anorexia tardive, cirrhosis, CRF
  • Functional: dysphagia, oral factors, feeding apraxia, visual loss, tremors, xerostomia, diabetic gastroparesis, ill fitting dentures
  • Neurological changes altering neurotransmitter regulators of food intake
  • Restricted diets, or inadequate oral intake
  • Need for increased diuretics

 

CLINICAL CONDITIONS WHERE MAINTENANCE OF ACCEPTABLE NUTRITIONAL STATUS MAY NOT BE POSSIBLE

  • Dementia
  • Refusal to eat or accept alternative feeding
  • Advanced disease (e.g., cancer, malabsorption syndrome)
  • Radiation or chemotherapy
  • Kidney disease
  • Chronic blood loss
  • Hyperthyroidism
  • Gastrointestinal surgery
  • Prolonged nausea, vomiting or diarrhea not relieved by adequate/acceptable treatments

 

PHYSICAL EXAMINATION

  • Pertinent to assess overall status with specific attention to: spare hair, skin pallor, tenting, wasting, skin integrity, ecchymosis, lymphadenopathy [parotidomegaly], hepatomegaly, perioral fissures
    Mouth: poor dentition, mucosal lesions
    Neck: thyromegaly
    Abdomen: spider angiomas, organomegaly, masses, ascites, fecal impaction
  • Neurological: mental status, focal signs + rule out depression as cause

 

DIAGNOSTIC WORK-UP

  • No DOH requirement to order any of their "suggested" tests, including albumin, plasma transferrin, hemoglobin, potassium, magnesium, cholesterol
  • NO SINGLE OBJECTIVE MEASUREMENT FOR THE DIAGNOSIS OF MALNUTRITION IS AVAILABLE FOR LTC RESIDENTS.
  • For initial evaluation consider: CBC, CMP, TSH, UCS. If PPD positive consider CXR.
  • Swallowing evaluation if any indication of dysphagia
  • Stools for occult blood if significant drop in hemoglobin since last check
  • Further labs to monitor improvement if treatment plan would be altered based on lab results

 

TREATMENT OPTIONS

  • Eliminate [where possible] drugs that may cause anorexia
  • Considering increasing fluid intake by written order
  • Place on weekly weights
  • Avoid special or restricted diets (decreased sodium or low fat) whenever possible
  • Dietary intake study with recommendations for nutritional enhanced meals or supplements
  • Nursing assessment with meal observations to assess functional changes and interventions
  • Change consistency of diet if directed by swallowing evaluation
  • Nutrition therapy: A: oral: nutrient dense supplements given with each med. pass or between meals and monitored on MAR - dietary to recommend based on modifications necessary for specific diseases, i.e. pulmonary- decreased CHO , renal - decreased protein, liver - increased branched chain amino acids, malabsorption - elemental formulas, lactose intolerance - lactose free formulas, constipation -increased fiber  B: tube feeding: (when accepted by resident and/or Health Care Agent and when it is documented that adequate nutrition cannot be maintained orally) - PEG feeding most acceptable for long term intervention - dietary to recommend based on condition of gut and expected degree of digestion - in residents where fluid intake needs to be monitored (HF or SIADH) use 2.0 kcal/cc density formula -monitor labs for hyponatremia - monitor resident for complications of tube feedings (aspiration pneumonia, diarrhea, skin irritation around tube site)
  • Pharmacological therapy: along with oral nutrition therapy, before considering tube feeding, consider:
    Reglan 5-10 mg 1 hr before meals to treat early satiation and anorexia from nausea or diabetic gastroparesis
    Megace 400 mg BID x 6 weeks. May use longer if patient has failed previous taper. Side effects include DVT and hyperglycemia. [May not be covered by the patientís PDP.]
    Dronabinol 2.5 mg HS especially for demented, agitated residents. After 1 week, administer the 2.5 mg dose before supper. If no improvement in 2 weeks give 2.5 mg before lunch and supper.
  • Remeron 15 mg HS if depression component [This will be covered by the PDP if given for weight loss caused by depression. Must be taken off all other antidepressants first.]
  • If Megace not effective consider Prednisone 2 mg QD - titrate up by 2-5 mg at weekly intervals
  • Terminal care: if weight loss is part of end-stage disease and no aggressive treatment is planned refer to Palliative Care Guideline for comfort measures as condition worsens

 

References for Weight Loss

  1. Council for Nutrition: Nutrition Literature Resource Compendium in Supplement to Annals of Long-Term Care, 2001.
  2. Gazewood, JD, Mehr, DR et al: Diagnosis and Management of Weight Loss in the Elderly in The Journal of Family Practice, Vol. 47, No.1 (July), 1998, 19-25.
  3. Holdcroft, C: Evaluating Involuntary Weight Loss in Older Adults in Nurse Practitioner, Vol.13, No.3/March 1988, 9-15.
  4. Kamel, HK, Thomas, DR et al: Nutritional Deficiencies in Long-Term Care: Part II Management of Protein Energy Malnutrition and Dehydration in Annals of Long-Term Care, Vol. 6, No. 8, July, 1998, 250-258.
  5. Leff, BA: Involuntary Weight Loss in the Elderly in Geriatric Medicine, Vol. 3, No. 1, January 2003, 31-38.
  6. Merck Manual of Geriatrics, Nutrition, 2nd Edition, 1995-1999.
  7. Morley, JE: Development of Guidelines for Use of Orexigenic Drugs in Lon-Term Care in Supplement to Annals of Long-Term Care, June 2003.
  8. Morley, JE, Thomas, DR: Update: Guidelines for the Use of Orexigenic Drugs in Long-Term Care in Supplement to Annals of Long-Term Care, June 2004.
  9. Morley, JE et al: Nutritional Deficiencies in Long-Term Care in Annals of Long-Term Care, Supplement, February, 2004, 1-7.
  10. Nicklaus, TM, et al: Serum Albumin as an Indication of Malnutrition in LTC Residents in Long-Term Care Interface, July 2003, 40-42.
  11. Thomas, DR, Kamel, HK et al: Nutritional Deficiencies in Long-Term Care: Part III OBRA Regulations and Administrative and Legal Issues in Annals of Long-Term Care, Vol. 6, No. 10, September, 1998, 325-332.
  12. Thomas, DR et al: Nutritional Deficiencies in Long-Term Care Part iii-OBRA Regulations and Administrative and Legal Issues in Annals of Long-Term Care, Supplement, February, 2004, 15-21.
  13. Thomas, DR, Morley, JE: Regulation of Appetite in Older Adults in Supplement to Annals of Long-Term Care, August 2002.
  14. White, HK: Weight Loss in Advanced Alzheimerís Disease, Part 1: Contributing Factors and Evaluation in Annals of Long-Term Care, Vol. 12, No. 5, May, 2004, 33-37.
  15. White, HK: Weight Loss in Advanced Alzheimerís Disease, Part l1: Interventions in Annals of Long-Term Care, Vol. 12, No. 6, June, 2004, 34-38.
  16. Wrede-Seaman, L.: Appetite Loss Assessment and Treatment in Symptom Management Algorithms A Handbook of Palliative Care, 2nd Edition, 1999, 20-21.
  17. Yeh, SS, et al: Improvement in Quality-of-Life Measures and Stimulation of Weight Gain After Treatment with Megestrol Acetate oral Suspension in Geriatric Cachexia: Results of a Double-Blind, Placebo-Controlled Study in JAGS, 2001, 48:485-492.

MS/11.99
©EMS
Revised 1.06

 

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