Wasting Away
Florence Gill, 93 and suffering from dementia, needed a little help each day dressing, bathing and eating. She was, by all accounts, doing well--until she entered a nursing home to recover from an eye infection.
In just four weeks, the 5-foot-1 former schoolteacher dwindled from 88 pounds to 72 pounds.
Her son Gerald visited twice a week but didn’t notice the weight loss because his mother was always covered by a blanket. Nurses assured him that she was eating.
By the time his mother was free of the infection, it was too late. Dehydrated, underweight and covered in bedsores aggravated by poor nutrition, she died in a hospice early last year--three days after leaving the nursing home.
“I try to watch things,” said Gerald Gill, a 63-year-old engineer who checked the home’s ratings on an Internet site and toured the facility before sending his mother there. “I was impressed. It didn’t smell like a lot of them.” He was encouraged that families of other residents seemed satisfied with the care.
Gerald Gill will never know exactly why his mother’s health deteriorated so rapidly, although it is clear that a lack of life-sustaining food and drink played a major role. Florence Gill is not alone. Although her situation may have been exacerbated by a nursing home staff that didn’t act aggressively enough or alert her family to her physical decline, thousands of other elderly patients in the nation’s 17,000 nursing homes are also wasting away from too little food or water.
Although nursing homes are required to keep records of how much residents eat and drink and to track their weight, it’s difficult for researchers to determine how often inadequate food and fluids play a role in their deaths. Death certificates rarely cite dehydration or excessive weight loss.
It is roughly estimated that 35% to 85% of the nation’s 1.7 million nursing home residents are at risk of malnutrition and dehydration. The range is broad because there have been no large national studies and there is no consensus on what health measures should be used. No matter the measure, the problem exists even at some of the “best”--or costliest--facilities.
Simply providing three square meals a day to an elderly resident doesn’t mean the meals are eaten. That’s because the reasons someone won’t eat can be complex. The aging process itself can dull one’s sense of taste or hunger, and illness and disability often are factors. Other reasons may include a dislike of institutional food or understaffed nursing homes that can’t provide enough individual attention for residents.
Thanks to better medications and other advances, people are living longer with chronic health problems. By the time they enter a nursing home, they tend to be older, with more illnesses and disabilities that can impair their ability to eat and drink.
Even seniors who still live at home can be undernourished, but the risks increase in hospitals, where busy staffs may provide only limited attention. Some studies estimate that 20% of hospital patients get less than half their needed nutrition.
The situation is most severe in nursing homes, where residents are dependent for most daily needs on low-wage, overworked nurses and nursing assistants. While nursing assistants typically feed from five to 20 people in about an hour, UCLA researchers found that it takes an average of 40 minutes for just one nursing home resident to finish a meal.
At greatest risk are frail seniors who must take multiple medications daily--some known to be appetite-killers. These people tend to have trouble seeing, hearing and tasting, as well as swallowing and chewing. They’re vulnerable to depression and prone to forgetfulness and declining mobility. And about half of them have dementia, which requires extra care during mealtime.
A recent UC San Francisco study of nursing home residents with eating problems found that inadequate staffing, lack of attention to food preferences and medical problems all were factors in why people weren’t eating.
The study, by UCSF nursing professor Jeanie Kayser-Jones, was based on observing 100 residents of nursing homes in the Pacific Northwest.
Among her observations:
* Nursing home workers often were so rushed that they “shoveled” food into residents’ mouths, causing choking and coughing.
* The food, while healthful, was sometimes served in unappetizing form: doled out in indistinguishable scoopfuls or pureed and mixed into a glass of milk.
* Food trays often were untouched by residents, and nutritional supplements weren’t consumed.
* Nurse assistants placed water pitchers out of reach or failed to open drink containers for residents with arthritic hands.
* Only one of 40 residents whose food and fluid intake she analyzed received the minimum fluid requirement (at least six glasses daily).
Some residents went without liquids for as long as 24 hours, according to Kayser-Jones, and some nursing assistants avoided giving liquids to incontinent residents so that they wouldn’t have to change clothes and bedding as often.
UCLA aging researchers have found in several related studies that about seven out of 10 nursing home residents fail to finish 75% of their food--the federal government’s yardstick for measuring the risk of malnutrition.
The researchers from UCLA’s Borun Center on Aging tried to encourage poor eaters by sitting with them at meals for extended periods over several days. Sometimes they would even place the food on a fork for the nursing home residents. Even so, only about half ate more than they had before, said Sandra Simmons, lead author of a study on feeding assistance due to be published soon in a gerontology journal.
“The picture is more complex than people think,” Simmons said.
The findings suggest that inadequate staffing or poor quality care are not the only explanations for why some elderly patients won’t eat, said Jack Schnelle, the Borun Center’s director. Even when the staff uses charm or persuasion to get older patients to eat, sometimes people “just don’t want the food.”
No Easy Answers When Residents Don’t Eat
People of all ages can lose their appetites when they are ill or depressed, but elderly people who don’t eat tend to suffer from “a kind of apathy . . . just not caring anymore,” Schnelle said. That could signal depression that’s been missed or that hasn’t responded to medication.
Their refusal or inability to eat or drink adequately puts nursing home staff in a difficult position. Does the staff respect residents’ wishes--and let them continue to eat only a small portion of their meal and continue to lose weight? Or do they adopt more aggressive measures, such as feeding tubes, to help them?
There are no easy answers. Family members sometimes object to invasive measures, such as feeding tubes, for the frailest, opting to let a loved one eat what they will and slowly fade away. Other times, they’ll agree to let doctors prescribe appetite-enhancing medications.
In the meantime, researchers at the Borun Center are studying how different approaches, such as more frequent but smaller meals and an improved variety of food, affect the eating habits of nursing home residents.
But “nothing is simple” with these patients, Schnelle said.
Many don’t realize they’re not eating enough.
Ask Florence Forman, 95, a resident of the Jewish Home for the Aging in Reseda, if she gets hungry or thirsty and she says: “No, I’m not usually hungry. I’m not usually thirsty.” With a little prompting, however, she will eat hard-boiled eggs, milk and fresh fruit--if the pieces are cut small enough.
Ida Glickman, another Jewish Home resident who turns 100 in August, thinks she’s a good eater. “I don’t leave much behind. I know I have to eat. I have to have strength to go around,” she says. But researcher Toby Smith said she typically finishes 30% of her meals. On a recent day and with prodding, she ate a bite of chocolate pudding and drank some milk--about 10% of her lunch. At 5 feet and 92 pounds, she’s at risk of undernourishment.
Sometimes, the elderly don’t want to speak up about problems that might explain their lack of eating, such as unappealing food. They don’t want to make trouble with the staff. As Glickman put it, “I’m not in a position to complain.”
Family members who notice an eating-related problem often act as advocates for nursing home residents. Sometimes they do the feeding themselves to assure that their loved ones are properly nourished.
Cindy Lynch was able to get her 94-year-old grandmother, Ruth Brewer Horton, out of a Tennessee nursing home where the 4-foot-11 Alzheimer’s patient wasted away to less than 55 pounds in two years.
Whenever Lynch would inquire about her grandmother’s weight loss, nursing home officials “said it was just the progression of the illness.”
But Lynch, who testified last year before a Tennessee legislative subcommittee investigating elder issues, knew better and got her grandmother into another nursing home, where Horton regained some weight.
New Guidelines for Nursing Care
The problem of malnutrition and dehydration in nursing homes was highlighted in 1998, when a U.S. Senate committee heard grim testimony about seniors dying in nursing care. A report followed from the General Accounting Office, the investigative arm of Congress, that attributed the deaths of some California nursing home residents to poor nutrition and dehydration.
The results prompted the federal Department of Health and Human Services in 1999 to institute new guidelines that dictate how nursing home investigators should evaluate weight loss, malnutrition and dehydration. They must review nursing home records (which must include any weight loss of 5% within 30 days or 10% within six months), interview health professionals and family members and personally observe at least two meals.
Advocates for nursing home residents blame short staffing, but many experts on aging say nutrition and hydration problems aren’t solved merely by mandating that a nursing aide is responsible for fewer people.
“It’s not something you can just legislate and regulate and say it will get done,” said Dr. David B. Reuben, chief of medical geriatrics at UCLA.
Creative Strategies Can Have a Positive Effect
But a little creative problem-solving--even in small ways--can make a difference.
A senior living center in Beachwood, Ohio, for example, began substituting protein-enhanced fresh fruit smoothies for expensive canned nutritional shakes that residents rarely finished. Residents so loved their new afternoon cocktail that they “would literally not leave the facility for organized activities until they had their fruit smoothie,” said Catherine Hawes, a public health professor at Texas A&M; University.
Another approach is to hire more staff to help with meals.
The Solheim Lutheran Home in Los Angeles hired a full-time nutrition coordinator to customize meals for residents and monitor their eating habits. Solheim also hired part-time nursing assistants to provide more hands-on help at dinner time.
Inadequate or indifferent care can be costly: Malnourished and dehydrated patients who undergo surgery often require longer hospital stays, Hawes noted. That’s an argument for spending more, early on, to ensure proper nutrition for nursing home residents, she said.
Meanwhile, Hawes said, improving how people eat and drink helps “save a lot in things you can’t quantify, like people’s quality of life and the decency with which they’re treated.”
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Where to Go for Help
Some sources of assistance and information on malnutrition and dehydration in the elderly:
* The California Department of Aging provides services to seniors through its Area Agencies on Aging offices. The 33 local offices can provide referrals to senior centers, where information is available about Meals on Wheels food deliveries and other meal services for seniors. The toll-free, statewide phone number, which connects callers to a local office, is (800) 510-2020.
* The California Long Term Care Ombudsman program, part of the state’s Department on Aging, provides help resolving complaints and problems involving long-term care facilities. Call (800) 510-2020 to be connected to a local aging agency office and ask for a referral to the ombudsman in your area. You also may call the Sacramento-based ombudsman crisis line for a local referral at (800) 231-4024.
* The California Advocates for Nursing Home Reform, a San Francisco-based advocacy group, provides assistance and information through a consumer help line, (800) 474-1116, and its Web site, https://www.canhr.org.
* The National Citizens Coalition for Nursing Home Reform, an advocacy group, provides information on nursing-home quality issues, including nutrition and hydration, and works with each state’s long-term care ombudsman program. Call (202) 332-2275 or visit its Web site, https://www.nccnhr.org.
