For the elderly, having regular weigh-ins is a fundamental part of their healthcare journey. As weight loss can be the first, and sometimes the only indicator of poor health. Commonwealth-subsidised residential aged care homes across Australia are governed by the National Aged Care Mandatory Quality Indicator (QI) Program.
Under this scheme, homes must measure and report on five quality indicators, one of these is unplanned weight loss to gain an understanding on how their processes are working and furthermore, make improvements to better their care. Though, like everything in healthcare, there is usually a grey area where residents may refuse to be weighed, their healthcare professional will recommend against weighing them or they are unable to be weighed due to their own health constraints.
This then makes it tricky for staff to monitor unintentional weight loss and malnutrition can easily be missed. Let’s take a look into different ways we can monitor and assess weight and nutrition status in aged care residents to further reduce the risk of unintentional weight loss and malnutrition.
Unintentional Weight Loss & Malnutrition in Aged Care
The impact of unintentional weight loss and malnutrition
Known as the “silent killer”, unintentional weight loss and malnutrition are far too common in the elderly population with statistics showing up to 50% of residents in aged care homes are malnourished or at risk. Weight loss is an indicator of overall morbidity and mortality in the elderly and can also increase the risk of hospital admissions and in-hospital complications, a decline in independence and function and reduced quality of life.
The Cause of unintentional weight loss and malnutrition
Unintentional weight loss in residential aged care may stem from a number of factors, some of which include:
Anorexia – as we age, the body experiences sensory changes which can impair our appetites. Reduced physical activity, disease, pain and an overall physiological reduction in energy needs can also reduce one’s appetite.
Physical illness – residents may experience nutrition impact symptoms (such as nausea, vomiting, diarrhoea, fatigue, constipation, reflux etc.) which can impact their oral intake. Other illnesses and diseases that carry a higher demand for nutrients such as cancer, cardiac or respiratory failure or chronic and poor healing wounds may make it difficult for residents to achieve their daily nutrient targets.
Cognitive illness – dementia and cognitive decline is a determinant to oral intake as residents may be unable to identify hunger/fullness cues, mealtimes and how to feed themselves. They may also be active wanderers who find it difficult to sit down and eat at mealtimes.
Dependence on others – a physical or cognitive decline in health can increase the dependence on others to help with feeding. For some, this can be embarrassing or uncomfortable and they tend to disengage in mealtimes.
Poor oral intake due to dislike - aged care home menus are diverse; however, it is impossible for homes to please all individual tastes and preferences at each meal. Food refusal due to dislike of the food is common, which in turn prevents residents from meeting their daily nutrition needs.
Swallowing and chewing impairments – a lack of dentition, ill-fitting dentures, refusal to wear dentures and impaired swallowing (dysphagia) may require a resident to transition to a modified texture diet/fluids which can limit their diet diversity and overall intake.
The Importance of Weighing Residents
Screening for unintentional weight loss and malnutrition
Due to the high prevalence of malnutrition in aged care, Dietitians Australia is pushing for malnutrition screening to become a mandatory component of the residential care admissions process. These tools are used to identify residents who are at risk of malnutrition without the need for diagnostic tests and interventions.
The most reliable malnutrition screening tools used in the aged care setting include the Mini Nutritional Assessment (MNA / MNA-SF) and the Malnutrition Screening Tool (MST) where parameters such as recent nutrition intake, neuropsychological problems, mobility and acute disease or stress may be measured. All screening tools use weight and/or body mass index (BMI) as an indicator and therefore, it is vital that residents in care are weighed regularly.
Quality indicator: unplanned weight loss
Collecting data on unplanned weight loss is a component of the QI program. This recognises two categories:
Significant unplanned weight loss, the loss of weight ≥ 3kg over a 3-month period.
Consecutive unplanned weight loss, the loss of any amount of weight every month over three consecutive months.
The directive is to measure the resident monthly (unless otherwise directed by the Doctor or Dietitian), around the same time and date, on the same weighing device and in clothing of a similar weight.
Other factors that can influence the weight recording may include fluid retention, diuretic use, meals (has the resident been weighed before or after a meal) and wet continence aids.
When not to be weighed
In some cases, weighing a resident is not feasible. If a resident has been assessed as palliative or for comfort care by the doctor, the resident does not require routine weighing as their goals of care are no longer for active intervention and therapy.
For residents who are immobile and bed bound, weighing can be a strenuous and uncomfortable task which may require sling lifters and specialised scales. This can increase the risk of bruising, skin tears and injury to the resident, especially if they are already frail and at risk. In this scenario, a risk assessment will be completed to determine whether or not it is safe and of benefit to the resident to continue weighing-in.
Residents and/or their next of kin also have agency to exercise choice and may wish not to be weighed as a personal preference.
How to Support & Monitor Residents Without the Scales
Alternative tools for assessing nutrition status
If a resident is no longer being weighed, there are other ways we can assess their nutrition status through observation and analysis. This may include monitoring their food consumption and performing physical examinations to identify inadequate nutrition intake or sarcopenia (muscle wastage).
Food and fluid charting | Monitoring dietary patterns is an effective way of identifying where a resident may be at risk of unintentional weight loss. If a resident has had a decrease in their daily food intake, is refusing food, not attending the dining room for meals, complaining of poor appetite or unable to complete their meal, mark these as red flags and report them to your dietitian. A good way to monitor intake is to complete a food and fluid chart as a dietary recall from a resident may not always be accurate. |
Clothing | A key indicator of unintentional weight loss can be seen in a resident’s clothes or jewellery. If you notice a loose watch band or ring, having to tighten a notch on a belt, a baggy jumper or pants that won’t stay up, these are all signs of weight loss and should be reported to the dietitian. |
Calf circumference | Measuring calf circumference is a good way to assess muscle mass which can be quick to deplete in malnourished residents. All you need is a tape measure! Position the tape around the widest point of the calf and record the result. A circumference less than 35cm for males and 34cm for females is indicative of muscle loss and should be reported. |
Other nutrition screening tools | Without weight, it is difficult to be able to complete a nutrition screening tool; however, you may wish to use components of the tool to identify risk. The PG-SGA has a physical exam component which includes the evaluation of body composition including fat, muscle and fluid. For this exam, you may wish to look at muscle status of the clavicles, shoulders, temples, calf and thigh, fat on the lower ribs and triceps and any fluid in the ankles or lower legs. If there is a deficit noted, this can be flagged and reported. Identifying metabolic stress and demand such as fever, infection and the prolonged use of corticosteroids can also increase risk of unintentional weight loss and should be monitored. |
Functionality | A decline in residents’ mobility, pace, strength, independence (unable to feed or shower themselves anymore) and alertness can be signs of muscle loss. You may want to call in on the physiotherapist or occupational therapist to conduct strength tests such as the chair-stand test, arm curl test or a hand grip strength test. |
Nutrition impact symptoms | Identify any nutrition impact symptoms that may be impacting the resident’s oral intake. It is unlikely that one or two episodes of diarrhoea or vomiting will cause significant harm; however, if chronic (for example for those on cancer treatment or episodes of gastroenteritis) the effects can be damaging. Nutrition impact symptoms to look out for may include:
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How to improve malnutrition rates and prevent unintentional weight loss in Aged Care
Staff of aged care homes have a major role to play in combatting malnutrition – whether through ensuring routine weight recording and malnutrition screening is completed; preparing and providing nutrient rich foods and fluids; identifying non-weight weight loss indicators or appropriately assisting residents with feeding.
It is also important to seek advice and support fro m an Accredited Practising Dietitian (APD), like us!, to assist with combatting unintentional weight loss in care. If you notice a resident has lost weight through weight recording data or other measures (as mentioned above), ensure they are referred immediately for an individual dietetic assessment. The Dietitian will be able to support staff in manipulating meals and mealtimes to suit the resident’s clinical condition and needs and offer oral nutrition support where required.
An OSCAR Care Group Dietitian can also assist with ongoing staff training about food fortification techniques, malnutrition screening and assessment, creating a positive mealtime environment and nutrition support to combat nutrition impact symptoms and poor appetites. Seasonal menu reviews are also recommended to ensure the menu provided is not only delicious and inviting, but meeting nutrition targets to minimise the risk of residents losing weight.
For more Information on malnutrition in aged care
For more information on malnutrition in aged care, malnutrition screening and assessment, or to seek advice and support from an APD, please reach out to your OSCAR Care Group Dietitian.
To access a copy of the MNA/MNA-SF and PG-SGA screening tools, please click here:
PG-SGA-Metric-version-4.3.20-std-logo.pdf (pt-global.org) mna-mini-english.pdf (mna-elderly.com) MNA-english.pdf (mna-elderly.com)
For more information on the QI program and how to record unintentional weight loss, please head to National Aged Care Mandatory Quality Indicator Program | Aged Care Quality and Safety Commission