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Wasting Away

Malnutrition and dehydration pull thousands of nursing home residents into a spiral of declining health. The causes, and possible solutions, are not as simple as one might suspect.


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).

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