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.