Older Patients, Wiser Care

When to Worry About Weight Loss and Poor Nutrition

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Dear Dr. K,

I'm worried about nutrition for my 84-year-old aunt, who lives alone. She has really bad arthritis, so it's hard for her to get out of the house, and she can't cook the way she used to. She's always been slim, but these days I worry that she's getting even skinnier! Would you recommend that she start drinking something like Boost or Ensure, and would I need a doctor's prescription in order to get it? I can't shake the feeling that she really needs to be eating better than she does.

Unintentional weight loss should always be a red flag for those of us caring for elders, so I'm glad this issue has caught your attention.

For some people, a fortified drink like Boost or Ensure can be really helpful. The key, however, is to first make sure that your aunt's weight issues really are best addressed with this type of nutritional supplement.

To figure this out, you'll want to do a little basic investigation as to what might be behind the weight loss. First, how much weight has actually been lost? One rule of thumb is that losing about 5 percent of original weight over 6-12 months should trigger investigation. (That corresponds to a 125-pound person losing 6 pounds.)

A medical check-up is almost always necessary. When you mention unintentional weight loss of 5-10 pounds, most providers will do some basic tests to check for common signs of major medical illness (i.e. cancer, thyroid problems, depression). Some chronic medical conditions, such as COPD, are also known to often affect appetite and weight.

Along with these medical investigations, you'll want to assess for more subtle problems that can interfere with an older person's nutrition. These are relatively common but easy to miss in the usual primary care visit:

Poor oral health: Painful teeth or dentures can cause an older person to eat less. But many older adults don't bring up this problem unless prompted, especially if memory or depression is an issue.

Trouble purchasing and/or preparing food: This can easily become challenging for an older person, if physical limitations (e.g. crippling arthritis) or memory problems are present. Financial difficulties can also be an obstacle to good nutrition.

Many older people have several factors affecting their appetite or their ability to get food. Once some of the underlying causes for weight loss are identified, have the doctor help you create a plan to address them. A registered dietician may also be able to give you specific advice regarding how many calories and how much protein your loved one should be getting every day.

Finally, plan on keeping track of your aunt's weight; try checking once a month, preferably with the same scale and types of clothes on. Be sure to let her doctor know if the weight loss continues despite efforts to stabilize it.

What about liquid supplements like Boost and Ensure? They certainly can be an easy way to provide calories and protein, especially if chewing or mouth discomfort has been an issue, and they have few side effects. You should know, however, that research studies haven't yet proven that supplementing malnourished adults in this way ends up helping them live longer or better. Some families find them helpful; for others they're expensive or the older person doesn't like drinking them.

High-calorie nutritional liquids are easily available without a prescription. They can also be prescribed by doctors; however insurance companies often don't cover the cost unless there's a diagnosis of cancer. Many families make the drinks more affordable by shopping online or in discount stores.

My prescription for caregivers worried about weight loss:

"¢ Try to document the weight loss, and be sure to get a medical check-up focused just on this problem "¢ Also be sure to check for some subtler problems that are more likely to be missed by a routine medical check-up. These include poor oral health (such as painful teeth or trouble swallowing), as well as difficulty obtaining and preparing food because of physical, mental, or financial limitations. "¢ There's usually little downside to trying a high-calorie liquid supplement like Ensure or Boost, but it may be hard to get these covered by insurance. These drinks are widely available over-the-counter. One low-cost alternative: Try mixing an instant breakfast powder with whole milk. "¢ Be sure to mention it to a doctor or registered dietician if your loved one continues to lose weight. A more thorough medical work-up might be necessary, or perhaps a revision of the family plan to maintain your loved one's nutrition.