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. 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

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. 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) Dont 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) Dont 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 residents 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 Quality of Care Life IndicatorData Source Threshold Resident not receiving a nutrition supplement & underweight Chart, SI, MDS > 15% Resident has a feeding tubeMDS> 16% Resident with weight lossMDS> 13% Resident with unplanned significant weight lossChart, MDS> 12% Resident with a feeding tube and significant weight lossChart, MDS> 1% Unplanned weight loss of 5% within 60 days of admission Chart, MDS> 21.7% Resident does not have access to fluidsRI> 1% Resident show physical signs of dehydrationRO> 1%

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. 2 nd ed. USA: ADA. Mahan L., & Escott-Stump S. (2004). Krauses Food, Nutrition, & Diet Therapy. 11 th ed. Philadelphia: Saunders. American Health Care Association. March 2009, from Centers for Medicare and Medicaid Services Web site: http://www.cms.hhs.govhttp://www.cms.hhs.gov Web site: http://www.ahca.orghttp://www.ahca.org Nursing Home Quality QIS Survey. 2007, Web site: http://www.nursinghomequality.com