Using Evidence-Based Organizational Strategies to Prevent Weight Loss in Frail Elders : Page 3 of 4

May 15, 2013

Dyck39 developed an evidence-based quality improvement program for the University of Iowa Gerontological Nursing Interventions Research Center. A copy of this protocol, titled Quality Improvement in Nursing Homes With Quick Reference Guide costs $35 and can be obtained by contacting the University of Iowa College of Nursing (Hartford Center of Geriatric Nursing Excellence) at

Educational Strategies 

Nurses typically do not receive extensive training in the nutritional issues of elders, including malnutrition and weight loss. Directing healthcare professionals to seek education focusing on signs of malnutrition and prevention of weight loss in the long-term care environment may positively impact residents.43,44 Nutrition education that aims at teaching nursing staff to recognize and respond to nutritional problems of their residents may have a positive impact on the total energy and protein intake of the residents.45

At a Finnish nursing home, Suominen and associates45 completed an 18-hour educational program to help nurses improve nutritional care of residents, none of whom had good nutritional status. The intervention was divided into 2- to 3-hour classes each month for 6 months. Each session included lectures, small group discussions, homework tasks, and personal feedback. After 1 year, 16% of residents had good nutritional status. Breaking up the educational hours enabled the professionals to internalize the aims of good nutritional care and intervene to enhance the nutritional status for the residents. Furthermore, this study found that strategies with a variety of components better facilitate understanding of information. Positive results were found when educational programming included presentations, discussion groups, out-of-class assignments, and individual feedback. Motivating healthcare professionals through presentations facilitated remembrance of facts concerning nutrition problems. Homework assignments included hands-on activities, such as weighing foods, keeping food diaries, using computer-based food record programs, and observing residents at meal times. Discussion topics included specific plans for individual adjustments to the residents’ diets and meal times. The use of discussions, readings, and teamwork enabled professionals to respond individually to the nursing home residents.

The purpose of an educational program may vary from facility to facility. For education programs to be successful, it is advisable to consult the facility’s dining room guidelines to identify learning needs of professionals. This enables the intervention to target specific learning deficits at the facility. Continuous training and education is important to meet the learning needs of the staff.46

In addition, it is important to encourage nurses to obtain gerontological nurse certification. As discussed in the Staffing Strategies section, research shows that staffing with nurses who have higher educational levels leads to lower mortality rates in patients in acute care settings.47 While this same research has not been completed in long-term care settings, it would appear that specialized nursing skills are necessary for nursing home patients as well.

Environmental Strategies

A high-quality dining experience may help prevent weight loss in frail elders. Factors affecting the dining experience include dining location, surroundings, food quality and choice, and good service.

Dining location. Where residents eat their meals can significantly impact nutritional care quality.48 A cross-sectional study in 34 nursing homes involving more than 700 residents found that residents who eat in a common dining room had better nutritional status than residents who ate in their rooms.48 This was attributed to the presence of nursing home staff in the dining room, as they could give feeding assistance to residents in need and accurately document food and fluid intake for the medical records. The authors of this study concluded that residents at risk of unintentional weight loss should eat their meals in a common area, such as the dining room, as opposed to being isolated in their rooms.

Dining room surroundings. Long-term care patients, especially those with dementia, may benefit from a more personalized and comfortable dining room, which may include hanging pictures on the wall and changing them occasionally, decorating the room with patterned tablecloths and curtains, and placing residents’ personal items in the room.49 Mamhidir and associates49 reported that personalizing the dining room was particularly effective in reducing weight loss risk in patients with Alzheimer’s disease and dementia. A study by Thomas and Smith50 found that individuals with dementia may consume 20% more calories when familiar background music is added to the dining surroundings. Routine seating plans can be particularly helpful for individuals with dementia51 due to their decreased ability to tolerate and adapt to environmental changes.52

Other common barriers in the dining room that may contribute to discomfort and distraction from eating include visual overstimulation, poor lighting, poor visual contrast, and auditory confusion.53 An easy fix for poor lighting is to turn up the lights or seating patients near windows, as increased light can decrease eye fatigue during the meal and make food easier to see. Similarly, patients with nutritional risk should not be seated in high-traffic areas, such as the middle of the room or by food serving areas. A decrease in people-generated and environmental-generated noises may improve acoustics and increase the quality of the dining experience.53

Food quality and choice. Food quality is often the most important predictor of patient satisfaction. Residents’ choice of foods encompasses views about menu selection to meet preferences as well as having options to choose food outside the established menus. Facilities have worked to accomplish choice and variety of foods by rotating the menu, trying new recipes,54 and having a refrigerator close to the dining area to facilitate substitutions.9 A sufficient staff of experienced cooks to serve food at correct temperatures is important, not only to ensure safety but also to improve satisfaction.

Service. Courteous servers who exude a caring attitude are important to quality dining environment. Staff can provide good service through family-style or buffet dining rather than serving meals on trays, which may result in increased socialization among residents with a more pleasurable mood and subsequent weight gain.49,55,56 In a continuing care retirement community, Hackes and colleagues55 demonstrated that family-style service resulted in significantly less food waste compared with healthcare-provider tray service and wait-staff service; however, changing to this style of service should take into account food and supply costs and meal acceptability, they concluded.