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Table of Contents

Introduction 6 Admission procedures 6 Monitoring weight loss 9 Standard Practice 10 The framework 1: assess for unintentional weight loss and trail 1st line interventions

12

The framework 2: if weight loss continues, assess and trail 2nd line interventions

17

The framework 3: if weight loss continues, assess and trail 3rd line interventions

23

The framework 4: if weight loss continues, assess and trail 4th line interventions

25

The framework 5: if weight loss continues, consider whether the causes of weight loss are irreversible

28

Procedures 1: weighing a resident 30 Procedures 2: measuring the height of a resident unable to stand 30 Procedures 3: calculating BMI 31 Procedures 4: what to discuss at the first family conference 31 Procedures 5: increasing the energy content of food 32 Procedures 6: fluid requirements and increasing fluid intake 32 Procedures 7: dysphagia: what care staff should look for and report 33 References 34 Weight & BMI monitoring chart 35 Food & fluid intake chart 36 Ed-FED Q scale for feeding problems 37 5% weight loss ready reckoner 38 BMI calculator 43 Tasks relating to the goals of care associated with weight loss 45 Acknowledgements 52

List of Figures Figure 1 Framework overview 3

Disclaimer These guidelines were written during the ‘Decision-making frameworks in advanced dementia: Links to improved care’ project, a partnership between the University of Western Sydney School of Nursing and Midwifery, College of Health & Science; Sydney West Area Health Service Primary Care & Community Health Network; and the Blue Mountains GP Network Ltd. Funded by the Australian Government Department of Health and Ageing under the National Palliative Care Program. The opinions expressed in this document are those of the authors and not necessarily those of the Australian Government. The information provided is a general guide only. Refer to the general practitioner and other members of the treatment team for decisions relating to care of individual residents. The information provided in these guidelines is based on the available best practice literature, or in the absence of this literature, expert opinion.

Figure 1: Weight loss framework overview

Weight loss framework for residents with advanced dementia

On admission: 1. give the family members a copy of the ‘severe & end stage dementia’ information

booklet; 2. identify the goals of care; 3. gather baseline data; 4. develop the nutrition care plan; 5. give out the ‘weight loss’ pamphlet before the first family conference; 6. weigh every week for 3 weeks.

1a. ASSESS . Aim to complete the assessment within 7 days:

1b. 1ST LINE INTERVENTIONS. Trial the interventions for 2 weeks

1. give extra help & allow extra time for the resident to eat; 1. assess how much the resident is eating; 2. increase the amount of food offered; 2. assess for common causes of eating problems; 3. seek additional advice if required, from speech pathologist, dietitian, general practitioner,

dentist; 3. then start 1st line interventions. 4. evaluate the outcome;

DOCUMENT THE INTERVENTIONS TRIALLED

NB consult a dietitian for assistance with menus and individual diets; and a speech pathologist for swallowing problems.

NB Every resident with advanced dementia is at HIGH RISK of weight loss.

If the resident loses weight per the criteria (without intent), then within 3 days: Assess further; and trial 1st line interventions

Standard practice: 1. provide daily food & fluids individualised to the resident’s needs; 2. provide daily mouth care; 3. weigh the resident & calculate the BMI monthly.

Continued on the next page

Decision-making frameworks in advanced dementia: Links to improved care project. of 52 Weight Loss Framework Guidelines.

2a. ASSESS. Aim to complete the assessment within 7 days: 1. review the goals of care; 2. refer to the GP for review of

reversible causes of weight loss; 3. review standard practice again;

2b. 2ND LINE INTERVENTIONS: Trial the interventions for 2 weeks

4. then start 2nd line interventions.

1. treat any reversible causes of weight loss; 2. provide energy– enriched foods & fluids; 3. start supplements if necessary; 4. continue to give extra help & allow extra time for the

resident to eat; 5. evaluate the outcome; 6. DOCUMENT THE INTERVENTIONS TRIALLED

Then: 1. continue to give extra assistance & allow extra

time for the resident to eat, and provide extra food as tolerated;

2. return to monthly weighing & BMI, unless the goals of care change;

3. if weight loss starts again, go to 2a and assess again, then start 2nd line interventions (2b).

3a. If weight loss has continued, assess further. Aim to complete the assessment within 7 days: Check whether the following are actually being given:

3b. 3rd line intervention: Trial the interventions for 2 weeks

1. all standard practice strategies; 2. additional time and assistance during meals

and snack times; 3. energy-enriched foods & fluids; Have the reversible causes of weight loss been addressed? Then start 3rd line interventions.

1. increase the quantity of energy-enriched

foods & fluids; 2. start or increase supplements; 3. evaluate the outcome; 4. DOCUMENT THE INTERVENTIONS

TRIALLED.

Then: 1. continue to give extra assistance & allow

extra time for the resident to eat, and provide extra food as tolerated;


3. if weight loss starts again, go to 2a and look for reversible causes of weight loss, then move to 3a, start 3rd line interventions (3b).

No Yes

Is the resident is still losing weight ?

Yes No


Continued on the next page


ision-making frameworks in advanced dementia: Links to improved care project. of 52 Framework Guidelines.

Then: 1. keep providing all standard practice in

the way food & fluids are offered + medication pass supplement + enriched foods;


3. move to no 5 and discuss causes of irreversible weight loss if weight is not maintained.

4a. If weight loss has continued, assess further. Aim to complete the assessment within 7 days: Check whether the following are actually being given: 1. all standard practice strategies; 2. additional time and assistance during meals

and snack times; 3. energy-enriched foods & fluids; Have the reversible causes of weight loss been addressed? Then start 4th line interventions.

4b. 4th line intervention: medication pass supplement. Trial the interventions for 2 weeks 1. continue to offer energy- enriched foods

and additional time and assistance; 2. commence a medication pass supplement; 3. evaluate the outcome; 4. DOCUMENT THE INTERVENTIONS TRIALLED.

Then: 1. continue to give extra assistance & allow extra

time for the resident to eat, and provide enriched food +/- supplements as tolerated;


3. if weight loss starts again, go to 4 and assess, then start 4th line interventions (4).

5. Then: Consider whether the cause of the weight loss is irreversible. 1. ask the GP to assess the resident for possible cachexia; 2. hold a family conference to discuss the weight loss. Include the GP, person responsible +/- other

family members, and members of the care team; If the consensus opinion is that this weight loss is irreversible, due to advanced

progressive disease, then: x STOP weighing the resident; x DOCUMENT in the care plan and resident’s notes that no further investigations or monitoring of weight loss will be done; √ provide food & fluids that the resident likes, that are of the right type, texture & consistency for the resident, +/- medication pass supplements if enjoyed; √ give ongoing emotional support and information to the family members; Continue with this regime until the resident is receiving end of life (terminal) care.

No

No

Yes No


Yes

Yes


DecWeight Loss

Introduction These guidelines are for nurses and care staff to use when managing weight loss in residents with advanced dementia (Mini Mental State Examination score < 10). For additional information, please refer to the ‘Supporting Information’ provided with these guidelines. Nursing competencies are also available to assist with education of residential aged care facility staff. NB: Registered nurses remain responsible for the assessment and care of residents at all times, even if they delegate tasks to other staff members to complete.

On admission of a person with advanced dementia

1. Give the person responsible +/- other family members a copy of the booklet: ‘Dementia information for carers, families and friends of people with severe and end stage dementia’. 2nd edition.

2. Identify the goals of care.

Discuss with the person responsible +/- family members, general practitioner and other members of the care team what the goals of care are. Goals of care should be discussed at every family conference relating to the resident’s clinical care. Is the resident to receive:

• active interventions, when you will look for and treat all causes of weight loss; • a palliative approach, where you will carefully monitor weight loss and manage

problems if they occur, with care focussed on maintaining the quality of life and comfort of the resident. Assessment for causes of weight loss will continue unless the person responsible and general practitioner +/- family members agree that limited assessment only will be undertaken. Care that focuses on the resident’s comfort, psychological, social and spiritual needs, and the needs of the person responsible and family members are always provided as part of the palliative approach; or

• end of life (terminal) care, when death is likely to occur in the next days or

weeks, and you will focus on resident comfort, and provide emotional support to the person responsible and family members.

The goals of care for a person with advanced dementia who loses weight should be realistic due to the progressive nature of the dementia. The focus of the goal of care for weight loss may not be to regain weight but rather to minimise any weight loss and to maintain independence. The goal of care for a person with end stage dementia who is cachectic should be comfort only.

Document the goals of care in the resident’s notes and on the care plan.


3. Gather baseline data. 3a: Assess the resident for his/her nutrition needs and look for the common causes of weight loss:

Assess:

• food & fluid preferences: size of meals, type & consistency of meals, cultural preferences including rituals associated with meals;

• ability to self-feed. Look for tremors, ataxia, weakness in hands and arms, joint pain;

• ability to chew and swallow food, ability to swallow fluids; • history of febrile episodes of unknown origin, or repeated chest infections, that

could indicate that the resident is aspirating food or fluids; • history of weight loss or appetite changes; • medical conditions known to cause weight loss: depression; nausea, vomiting

constipation or diarrhoea; fluid retention or infections; problems with mouth, teeth (including dentures) & gums;

• review the medications the resident takes. Dioxin, antibiotics and non-steroidal anti-inflammatory medications are commonly associated with nausea, vomiting & diarrhoea. Look for any that may cause weight loss;

• complete a physical assessment, including a pain assessment.

Every resident with advanced dementia is at HIGH RISK of weight loss. Seek advice from the general practitioner and/or a dietitian and/or a speech pathologist as appropriate if there are medical problems associated with weight loss; daily menus and meal planning; and/ or ability to swallow noted on admission. Further assessment may be required STOP: LIMIT FURTHER ASSESSMENTS IF:

• the goal of care is for end of life (terminal) care; or

• the goal of care is a palliative approach, and during the goals of care discussion it is agreed that further assessment will be limited. Food will be given for the resident’s comfort and pleasure.

Limited assessments mean:

• no weighing the resident or calculating the BMI; • no pathology tests to establish the causes of weight loss; • no X-Rays to establish the causes of weight loss; • no other diagnostic tests to establish the causes of weight loss.

The following assessments and care WILL CONTINUE:

• assessing the resident regularly for feeding difficulties; • assessing the resident regularly for swallowing difficulties;


• the ‘standard practice’ of daily food & fluid provision will be monitored. Full assistance will be given for feeding as required;

• food and fluids will be given that the resident likes and that are the right type & consistency for the resident.

If the resident is receiving end of life (terminal) care:

• the resident’s level of consciousness and ability to swallow will be assessed at least daily before offering food & fluids. If the resident is receiving end of life (terminal) care and is unable to swallow, appropriate mouth care only will be offered.

DOCUMENT the reasons for the decision to limit further assessments in the resident’s notes. Make sure the care plan reflects the goals of care. Record on the weight chart that no further assessment is required.

3b Assess for under nutrition:

• use the Mini Nutritional Assessment (MNA tool) ; • weigh the resident; • measure the resident’s height. NB: do not rely on the memory of family

members. Height reduces with age; • calculate the resident’s body mass index (BMI).

3c Complete baseline pathology tests: (There is no need to repeat these tests if the resident has had blood tests in the past 3 months).

Review the results of these pathology tests:

• serum albumin; • multiple biochemical analysis (MBA 20); • fasting blood sugar level; • B12 levels; • thyroid function tests.

4. Develop a nutrition care plan based on the needs & preferences of the resident.

5. Give the resident and/or the person responsible +/- family members a copy of the pamphlet ‘Weight loss in advanced dementia’ to read before the resident’s first family conference is held in the facility.

6. Weigh weekly for 3 weeks to gather baseline data on weight.

This completes the weight loss section of the admission.


Monitoring

Monitoring for weight loss (weighing and BMI calculation) should occur:

• monthly, if weight is stable;

• weekly while the resident is losing weight and is receiving assessment and interventions for weight loss; UNLESS

there is a documented discussion that further assessment should be limited.

A registered nurse needs to review the weight & BMI chart:

• monthly, if weight is stable;

• weekly, if assessment and interventions for weight loss are being implemented.

Criteria for weight loss1 that needs assessment and intervention:

• a weight loss of 5% in one month, 7.5% in 3 months, or 10% in 6 months; • a decline in food intake over several days (not to exceed 7 days) noted by family

or staff that is not associated with acute illness or starting a new medication. An abrupt change, when food is refused for two or more successive meals, is usually associated with acute illness or starting a new medication;

• a slow decrease in the BMI to <19; • persistent, unexpected and unintended weight loss for 3 consecutive months.

If any of these criterion are met, proceed within 3 days to 1st line assessment and intervention.


Standard Practice Prevention of reversible causes of weight loss in residents improves the quality of life and comfort for the resident and is more cost effective for the facility. The following standard practice should be undertaken continuously:

1. Provide daily food & fluids: • provide foods and fluids ‘by the clock’. A resident with advanced dementia will

not recognise hunger or thirst, so will not ask for food or drink; • check regularly that the foods provided each day are those that the resident

likes; that the foods are culturally appropriate; of the right consistency and quantity for the resident; and provide sufficient energy to maintain weight;

• regularly assess the resident for swallowing problems, and refer to a speech

pathologist for recommendations if dysphagia is a problem;

• residents with advanced dementia rarely need dietary restrictions. Discuss with the general practitioner and remove any that are inappropriate;

• residents with diabetes should be able to have a small amount of sugar on their

cereal and in their milk drinks;

• make sure that residents being given thickened fluids and pureed foods are still offered snacks at morning and afternoon tea;

• make food as attractive as possible, include garnishes and seasonings to

increase the appearance and taste of the foods;

• provide finger foods so the resident can feed him/herself and maintain independence;

• provide feeding aids to maintain the resident’s independence;

• provide sufficient fluids each day (approximately 8 cups per day);

• arrange for the resident to receive as much assistance for feeding as he/she

needs, encourage eating but do not force the resident to eat;

• allow plenty of time for feeding the resident, or supervising the resident while he/she eats;

• make sure the environment is pleasant and not overstimulating during meal

times;

• make sure the person feeding the resident sits at eye level to improve the resident’s social well-being;

• make sure the resident is positioned so he/she will not choke.


If the resident is receiving end of life (terminal) care:


2. Provide daily mouth care2: • problems with the mouth, teeth and gums can be reduced by good oral hygiene

and regular assessment; • the resident’s mouth should be rinsed with water, and his/her teeth cleaned

with a soft toothbrush, toothpaste and water;

• refer to a dentist, or seek advice from the general practitioner if problems with the mouth, teeth and gums occur.


The Framework

An overview of the framework can be found in Figure 1 in this document.

1. If the resident unintentionally loses weight per the criteria, then within 3 days:

1a. start to assess further (complete within 7 days); then 1b. trial 1st line interventions

The most common reason for weight loss among people living in residential aged care facilities is insufficient care: not enough time and assistance are provided to enable the resident to eat enough food. 1a. Assess further Registered nurse (RN) or delegate:

• check whose responsibility it is to recalibrate the scales. Organise regular recalibration if there is a problem with the scales’ accuracy;

• confirm that the weight loss is really unintended or unexpected: discuss

with the care staff and family members; • ask the care staff to re-weigh the resident to validate the previous

measurements if you think the weight is inaccurate. If reweighing validates that weight is lost, commence further assessment:

a) Assess how much the resident is eating:

• ask the care staff to monitor and record the resident’s food intake for 1-3 days to establish how much food the resident is actually eating, and when he/she is eating it. Use a form such as the example attached to this document, to gain an accurate picture of what is being consumed and when; then:


b) Assess for common causes of eating problems:

• Observe the resident during a meal to see how much assistence he/she is

receiving; and for signs of swallowing difficulties; • are there new dental and oral health problems affecting eating? Check the

mouth, and discuss the daily mouth care with the care staff. Direct the care staff to alter the mouth care protocol if necessary;

• check with the care staff whether signs of dysphagia are apparent: food sticking

in the throat; choking or coughing when being given food or fluids; dribbling a lot; difficulty chewing or moving the bolus (ball of food in the mouth); taking longer to finish a meal; holding food or fluids in the mouth and not being able to start swallowing. See procedures section for a more detailed list. Consider nil by mouth if dysphagia is present until a full assessment can be completed by a speech pathologist. Discuss with the general practitioner;

• review the resident for common medical causes of weight loss, including pain or

constipation, which can affect the amount of food eaten. Discuss with the care staff whether there have been behavioural changes that could indicate discomfort. Complete further nursing assessment if necessary.

• review the current diet: is the resident receiving enough energy from food to

compensate for behaviors such as wandering or pacing?; • does the resident like the food offered? The resident may prefer sweeter or

spicier foods. Ask the care staff and family members; • is the resident still receiving a therapeutic diet? Discuss with the general

practitioner and stop if possible (especially low fat diets);

• is enough feeding assistance available?; • has enough time been set aside for the resident to eat slowly?;

• are there environmental factors distracting the resident when eating?

• ask a care staff member who regularly feeds the resident to complete an Ed-

FED scale for feeding difficulties (a copy is in the back of these guidelines);

• discuss with the care staff whether the resident’s ability to self-feed has changed.

Care staff:

• reweigh the resident if requested to do so by the RN;


• complete a daily food & fluid record for 1-3 days, if requested by the RN. Ask for training if you are unsure how to measure the food and fluids, or complete the chart;

• complete an Ed-FED scale for feeding difficulties if requested by the RN. Ask

for training if you are unsure how to complete the scale;

• report to the RN any changes you have noticed in the way the resident eats and drinks. Can the resident still feed him/herself? Have swallowing problems started?;

• report to the RN or person in charge if the resident’s behaviour indicates discomfort eg agitated, restless, aggressive, more confused than normal, more quiet than usual, seeing or hearing things that aren’t there;

• participate in all discussions relating to the way food and fluids are provided.

Review all the evidence collected, then move to implement 1st line interventions immediately. Tailor the interventions to the findings.

1b. 1st line interventions, based on the findings of the

assessment.

(1st line interventions are to give extra help & allow extra time for the resident to eat)

Trial these strategies for two weeks, then review. Registered nurse (RN) or delegate:

1. Give extra help and allow extra time for the resident to eat:

• supervise the care staff so that the resident receives additional assistance to eat and drink, during every meal, and snack times;

• direct the care staff to provide extra time for the resident to complete meals if

the resident is slow in eating. Review for swallowing problems. Needing extra


time to eat may be a sign that dysphagia is starting. Advise kitchen / domestic staff if necessary, so that plates will not be removed too quickly;

• direct the care staff to encourage the resident to eat, without forcing him/her.

2. Increase the amount of food offered: • ask a dietitian to review the resident’s diet and individualise the meal plan.

Provide him/her with a copy of the completed food intake charts previously completed as evidence of the usual pattern of food consumption;

• discuss with the cook/kitchen staff and increase the size and quality of between-

meal snacks. E.g. give the resident a muffin rather than a plain biscuit. Check that residents receiving thickened fluids and pureed food are being offered food and fluids at morning and afternoon tea times, and supper;

• direct the care staff to increase the fluids being offered to the resident. Aim to give between 50ml-100ml every hour while the resident is awake, unless medically contraindicated.

3. Seek additional advice if required:

• refer to the speech pathologist if necessary for swallowing problems, and follow the recommendations given. Discuss any recommendations in full with the care staff. Copy the recommendations and place them where care staff can see them during meal times if there is any doubt that they are not being followed;

• seek dental assistance if necessary to improve the condition of the resident’s

mouth, teeth, gums or dentures. Discuss any recommendations in full with the care staff;

• refer to the general practitioner if necessary and treat medical causes of weight loss that have been identified.

Care staff:

• feed the resident slowly and carefully. Engage his/her interest by chatting to the

resident. Sit at eye level to feed. Don’t overload the spoon, and watch carefully for signs that the resident is having swallowing problems;


• position the resident correctly. Follow the speech pathologist’s recommendations;

• never force the resident to eat;

• discuss with the RN and other care staff if a resident is developing aversive behaviours (eg turning his/her head away from the food; allowing food to drop out of the mouth). Complete an Ed-FED scale and give to the nurse in charge, so that all nurses and care staff can discuss and decide what action to take in the resident’s best interests. A family conference may be required.

4. Evaluate the outcome of this intervention:

• weigh the resident each week for two weeks;

• if the weight loss is reversed (weight is stable, or weight is gained) at the end of

two weeks, continue with the 1st line interventions you have started;

• resume monthly weighing and calculation of the BMI.

• if further weight is lost, move immediately to the next level of

assessment and 2nd line interventions;

• inform the person responsible and family members of the results of the assessment and interventions;

• make sure the resident’s notes and care plan reflect accurately the interventions undertaken and the outcome of the interventions.


If weight loss continues: 2a. start to assess further (complete within 7 days); then 2b. trial 2nd line interventions

If the resident continues to lose weight after 2 weeks of providing additional help and time with eating/feeding, then assess him/her further. Commence this assessment immediately after the evaluation of the 1st line interventions has shown that weight loss is continuing.

Complete all of this additional assessment within 7 days.

1. Review the goals of care.

Are the goals of care still relevant for the resident? For example, if the resident’s dementia has progressed towards end stage, the person responsible and family members need to know that further assessment of weight loss might cause discomfort and distress to the resident. The resident may need pathology tests and X-Rays, and may need to be taken from the facility to have the tests completed.

• give the person responsible and family members a copy of the pamphlet

‘Weight loss in advanced dementia’ if they haven’t received a copy or don’t remember it;

• assess the resident to see whether dementia progression has occurred;

• discuss the goals of care with the person responsible and the family members and general practitioner before proceeding further with assessments.

STOP: LIMIT FURTHER ASSESSMENTS IF:

• the goal of care is for end of life (terminal) care; or

• the goal of care is a palliative approach, and during the goals of care discussion it is agreed that further assessment will be limited. Food will be given for the resident’s comfort and pleasure.

Limited assessments mean:

• no weighing the resident or calculating the BMI;


• no pathology tests to establish the causes of weight loss; • no X-Rays to establish the causes of weight loss; • no other diagnostic tests to establish the causes of weight loss.


• assessing the resident regularly for feeding difficulties; • assessing the resident regularly for swallowing difficulties; • the ‘standard practice’ of daily food & fluid provision will be monitored. Full

assistance will be given for feeding as required; • food and fluids will be given that the resident likes and that are the right type &

consistency for the resident. If the resident is receiving end of life (terminal) care:


DOCUMENT the reasons for the decision to limit further assessments in the resident’s notes. Make sure the care plan reflects the goals of care. Record on the weight chart that no further assessment is required.

2. Refer to the general practitioner for review of the treatable causes of weight loss:

Registered nurse (RN) or delegate: Before contacting the general practitioner:

• review the resident’s fluid intake. Direct the care staff to record a fluid intake chart for 1 –3 days;

• review the resident’s behavior: is depression a problem? Screen for depression

using the Cornell Scale for Depression in Dementia;

• complete a urinalysis, review the bowel chart for constipation, direct the care staff to complete a pain assessment tool each shift for 1-3 days.

Care staff: • complete a fluid intake chart as directed by the RN;

• discuss the resident’s behaviour with the RN and other members of the care

team. Have there been changes that indicate depression (more withdrawn, quieter, apathetic? Has the resident been uncomfortable due to pain,


constipation, an infection? Complete a pain assessment tool as directed by the RN or nurse in charge.

Report the findings of the reviews of fluid intake, depression, urinalysis, pain, constipation to the general practitioner and ask him/her to consider whether the weight loss is due to a reversible cause such as:

• fluid and electrolyte imbalance; • depression;

• medications known to affect weight loss;

• chronic infections affecting weight loss; • metabolic disorders such as hyperthyroidism.

The resident may need the following procedures to establish a diagnosis: • pathology tests: eg full blood count; metabolic profile (liver enzymes, total

protein and albumin, calcium and phosphorus, cholesterol and magnesium); thyroid function tests;

• chest x-ray;

• urine culture;

• digital rectal examination.

3. Go back and review the standard practice of providing food, fluids and mouth care (see page 10).

4. Start 2nd line interventions.


2nd line interventions, based on the findings of the assessment. (2nd line interventions are to treat potentially reversible causes of weight loss and provide energy-enriched foods & fluids).

Implement these strategies for two weeks, then review. Registered nurse (RN) or delegate:

1. Treat any reversible causes of weight loss:

• follow the recommendations of the general practitioner to treat any potentially reversible causes of weight loss.

2. Provide energy-enriched foods & fluids: • if the facility has a high-energy nutrition menu, commence the resident on it; • provide high-energy snacks;

• offer increased amounts of high-energy fluids, such as milkshakes and smoothies;

• seek advice from a dietitian if an individual nutrition plan is required. The ‘Supporting Information’ and page 30 of these guidelines provide some suggestions for enriching foods and fluids. Discuss with the appropriate people in the facility how the enriched foods will be supplied and who is responsible for this to occur. If additional energy is not being reliably consumed by the resident from the food & fluids offered in the facility, then a supplement of an oral nutrition support product(s) (eg Ensure) can be trialled. These are available as fluids, powders and puddings and come in a variety of flavours. NB: best practice care for a resident losing weight is to provide food & fluids based on an individualised nutrition plan. Research has revealed that over half of the residents studied being given supplements didn’t like the supplements, and almost half of the supplements were not consumed and were wasted each day. Additionally, there is some evidence that using


supplements may actually suppress the resident’s appetite, so the resident eats less ordinary food each day. Offer supplements at least one hour before meals to reduce the chance of appetite suppression. If supplements are to be used, discuss with the person responsible and family members first. Note that these supplements are unlikely to produce weight gain in a resident who is already cachectic. After discussion and agreement to proceed:

• direct the care staff to assist and encourage the resident to eat / drink 125ml nutrition support supplement at morning tea and either afternoon tea or supper;

• direct the care staff to assist the resident to drink a full 250ml serve of a

nutrition support supplement if the resident misses eating a meal. Care staff:

• assist with giving enriched foods and fluids as ordered;

• offer supplements as ordered. Report to the nurse in charge if the resident is not eating / drinking the supplements.

3. Continue to give extra help and allow extra time for the resident to eat.

4. Evaluate the outcome of this intervention

• weigh the resident each week for two weeks;

• discuss with the care staff whether the supplements are being consumed and enjoyed. Review the bowel chart for changes that may have occurred since the introduction of the supplements, and amend bowel care program if necessary;

• if the weight loss is reversed (weight is stable, or weight is gained) at the end of two weeks, continue with this strategy;


• if further weight is lost, move immediately to the next level of

assessment and 3rd line interventions;


• inform the person responsible +/- family members of the results of the assessment and interventions;

• make sure the resident’s notes and care plan reflect accurately what intervention was undertaken and the outcome.


If weight loss continues: 3a. start to assess further (complete within 7 days); then 3b. trial 3rd line interventions

If the resident continues to lose weight after treating any reversible causes of weight loss, and giving him/her enriched foods & fluids for 2 weeks, with or without supplements, then further assessment is required before moving to the next line of interventions. Commence this assessment immediately after the evaluation of the 2nd line interventions has shown that weight loss is continuing.


Check whether the following strategies are actually being undertaken:

8. all standard practice strategies;

9. providing additional time and assistance during meals and snack

times;

10. providing energy-enriched foods & fluids, with or without supplements.

Have the treatable causes of weight loss been addressed? Seek advice from a dietitian if you have not already done so for this resident. Then start 3rd line interventions.


3rd line interventions, based on the findings of the assessment. (3rd line interventions are to increase supplements).

Implement these strategies for two weeks, then review If the resident does not tolerate the increased volume of these supplements, move straight to 4th line interventions. Check with the care staff after the first 2-3 days of trialling the additional nutrition support supplements.

1. Increase supplements or commence supplements

If the resident has not been trialled on an oral liquid supplement, commence per 2nd line intervention:

• assist the resident to eat / drink 125ml nutrition support supplement at morning tea and either afternoon tea or supper;

• if the resident does not eat a meal, assist him/her to eat/drink a full 250ml serve of a nutrition support supplement if possible.

If the resident is eating / drinking & enjoying the nutrition support supplements, but still losing weight, then :

• increase the nutrition support supplements to 500ml per day; • give 125 ml per serve, four times per day, after offering breakfast, lunch, dinner

and supper; • provide a range of flavours so the resident doesn’t get tired of the same taste; • continue all previous interventions plus all standard practice recommendations.

2. Evaluate the outcome of this intervention: • weigh the resident each week for two weeks;


two weeks, continue with this strategy;

• resume monthly weighing and calculation of the BMI. • if further weight is lost, move immediately to 4th line interventions;

• inform the person responsible +/- family members of the results of the

assessment and interventions;



4. If weight loss continues: 4a. start to assess further (complete within 7 days); then 4b. trial 4th line interventions

If the resident continues to lose weight after treating any reversible causes of weight loss, and giving him/her enriched foods & fluids, and supplements, for 2 weeks, then further assessment is required before moving to the next line of interventions. Commence this assessment immediately after the evaluation of the 3rd line interventions has shown that weight loss is continuing.


Check whether the following strategies are actually being undertaken:

1. all standard practice strategies;

2. providing additional time and assistance during meals and snack

times;

3. providing energy-enriched foods & fluids, and supplements. Have the treatable causes of weight loss been addressed? Seek advice from any allied health specialist necessary: speech pathologist, dentist, dietitian if you have not already done so for this resident. Then start 4th line interventions.


4th line interventions, based on the findings of the assessment. (4th line interventions are ‘medication pass’ supplements).

Implement these strategies for two weeks, then review.

1. Continue to provide energy- enriched foods and additional time &

assistance:

• offer the resident foods and snacks of the right texture that he/she likes; • enrich them whenever possible; • assess intake of nutrition support supplements commenced during 2nd or 3rd

line interventions. Cease offering them if the resident will not consume them. 2. Commence a ‘medication pass’ supplement:

‘Medication pass’ supplements are given 3 to 4 times per day, when the resident’s regular medications are given. NB giving these supplements as part of the medication round has been shown to decrease cost and wastage.

• commence the resident on one of the nutrient dense formulas that are available eg TwoCal (Abbott); Novasource 2 (Novartis). One millilitre of these products typically contains 2 kcal.

• give 60ml of the nutrient dense formula 3 to 4 times per day, with the resident’s medications UNLESS the medications cannot be taken with food. This will give up to an additional 480 kcal per day;

• check with the GP or pharmacist if you are unsure about which medications can be given at the same time as these products;

• titrate the amount of nutrient dense formula the resident receives if necessary or review the prescription if the resident shows signs of intolerance eg loose stools.

3. Evaluate the outcome of this intervention: • weigh the resident each week for two weeks;


two weeks, continue with this strategy;


• if weight loss continues despite all the above interventions then consider whether the weight loss is irreversible.


• inform the person responsible +/- family members of the results of the

assessment and interventions;



5. If weight loss continues:

consider whether the cause of the weight loss is irreversible

If the resident continues to lose weight despite all the above interventions then you need to consider whether the weight loss is unavoidable, due to cachexia from advanced disease. Assessment at this time is important, as the prognosis of the resident will be discussed, and the goals of care and care plan of the resident will be impacted 1.

1. Ask the GP to assess the resident to see if he/she is cachectic;

2. Hold a family conference to discuss the weight loss:

• invite the person responsible +/- other family members, members of the multidisciplinary care team and the GP;

• discuss the resident’s medical condition, dementia progression, other co-morbidities, prognosis, and most appropriate methods of providing comfort care;

• discuss the issues of weight loss experienced by the resident, and the interventions trialled to date;

• discuss the burdens and benefits of invasive procedures aimed at preventing further weight loss, such as insertion of PEG tubes for artificial feeding;

• discuss dysphagia, including what the plans will be if the resident repeatedly aspirates. The ‘Supporting Information’ provides further information.

If the consensus agreement of those present at the case conference is that weight loss is cachectic in nature and therefore irreversible, then:

• stop weighing the resident or monitoring weight loss; • stop investigating the causes of weight loss; • provide limited assessments per the criteria listed below; • continue to treat reversible causes of weight loss that are symptomatic and

causing distress to the resident; • provide foods and fluids that the resident likes, of the right texture so the

resident can swallow them; • continue medication pass supplements if the resident enjoys them; • provide ongoing emotional support and information to the person responsible

+/- the other family members; • review the goals of care so that comfort care only is the priority.


Refer to the ‘Supporting Information’ for further information relating to artificial nutrition and hydration. Limited assessments mean:

• no weighing the resident or calculating the BMI; • no pathology tests to establish the causes of weight loss; • no X-Rays to establish the causes of weight loss; • no other diagnostic tests to establish the causes of weight loss.


• assessing the resident regularly for feeding difficulties; • assessing the resident regularly for swallowing difficulties; • the ‘standard practice’ of daily food & fluid provision will be monitored. Full

assistance will be given for feeding as required; • food and fluids will be given that the resident likes and that are the right type &

consistency for the resident. DOCUMENT the reasons for the decision to limit further assessments in the resident’s notes. Make sure the care plan reflects the goals of care. Record on the weight chart that no further assessment is required. Continue with this regime until the resident is receiving end of life (terminal) care.


Procedures

Weighing a resident

• make sure the scales are accurate (calibrate if necessary); • use the same scales each time; • weigh the resident at the same time of the day each time, preferably before

breakfast; • dress the resident in the same clothes each time eg pyjamas if weighing before

breakfast. A ‘ready-reckoner’ is available in the back of these guidelines to calculate 5% weight loss among residents weighing between 30kg and 102 kg.

How to measure the height of a resident unable to stand to be measured.

If the resident is unable to stand to be measured, then calculate the height with the formula provided below. To measure the length of the lower leg from the bottom of the heel to the top of the knee cap: sit the resident in a chair with bare feet flat on the floor. The knee joint should be at a right angles to the floor. Measure from the bottom of the heel on the floor to the top of the kneecap. Calculate using this formula3: For females: 84.88 – (0.24 x age) + (1.83 x knee height in cm). For example, Mrs Smith is an 82 year old. Her knee height is is 47cm. (0.24 x 82 (age) = 19.68. (1.83 x 47 (knee height) = 86.01 84.88 – 19.68 + 86.01 = 151.2 cm Mrs Smith is 151.2 cm tall. For males: 64.19 – (0.04 x age) + (2.02 x knee height in cm) For example, Mr Johnstone is 91 years old. His knee height is 55cm (0.04 x 91 (age) = 3.64. (2.02 x 55 (knee height) = 111.1. 64.19 – 3.64 + 111.1 = 171.6cm Mr Johnstone is 171.6 cm tall.


How to calculate the body mass index (BMI)

The BMI is calculated by dividing weight in kilograms by height in metres squared (m2). For example, Mrs Smith (above) weighs 50kg, and is 1.51 metres tall. 1.51 2 = 2.28. 50 (kg) / 2.28 = 22 (21.9 rounded to next highest figure). Mrs Smith has a BMI of 22 and is within the healthy weight range. Mr Johnstone (above) weighs 53kg, and is 1.71 metres tall 1.71 2 = 2.92 53 (kg) / 2.92 = 18. Mr Johnstone has a BMI of 18 and is very underweight. He requires immediate assessment to understand the causes of his weight loss. A BMI ready-reckoner is attached to assist with calculation of the BMI. Numerous internet sites provide BMI calculators to instantly calculate a BMI. One site is: http://www.betterhealth.vic.gov.au/bhcv2/bhcsite.nsf/pages/bmi?open

Enter the height (in metres) and the weight, the BMI will be calculated for you.

What to discuss about weight loss in advanced dementia during the resident’s first family conference

• weight loss across the dementia trajectory; • potentially reversible causes of weight loss; • irreversible causes of weight loss; • common feeding problems in advanced dementia, and how they are managed; • need for dietary restrictions and therapeutic diets; • how weight loss is monitored and the criteria for interventions; • interventions, including enriching foods, giving supplements, altering food

texture for swallowing deficits, and the benefits and burdens of tube feeding.


http://www.betterhealth.vic.gov.au/bhcv2/bhcsite.nsf/pages/bmi?open

How to increase the energy content of foods & fluids

For residents unable to eat large amounts, the best first option is to increase the energy content of the daily foods. Simple ideas for increasing the energy content of foods include:

• adding extra butter or margerine to mashed potato and other vegetables; • adding cheese to mashed potato, pasta, casseroles, scrambled eggs; • adding cream to desserts and porridge; • adding skim milk powder to milk, soup, porridge, white sauce, cheese sauce,

baked custard; • offering additional finger foods.

A dietitian can provide suggestions that are appropriate for individual residents.

See the ‘Supporting Information’ for further ideas.

Fluid requirements and how to increase fluid intake

• the recommended intake of water (over and above the water available from foods and by-products of metabolism) for older people in residential aged care is a minimum of 1600ml every 24 hours. This is approximately 8 glasses or cups (200ml size) per day;

• in certain conditions such as heart failure this amount of fluid may need to be restricted;

• fluid can also be provided in the form of soups, fruit juices, yoghurt, milkshakes and smoothies, chocolate drinks such as Ovaltine, Milo and Aktavite, and soup-in-a-cup.

Tips for increasing fluid intake 4:

• for residents who do not recognise a cup or glass placed on the table, put the glass in the resident’s hand and show him/her what needs to happen;

• milk and fruit drinks are more easily seen in clear drinking glasses; • use small cups or tumblers, they are easier to manage; • prompt the resident to remind him/her to drink regularly; • develop strategies to promote hydration tailored to assist the staff giving care.

eg build drinks breaks into every activity being undertaken in the facility; • cognitively impaired residents might respond better if they are offered a choice

of drinks when being prompted to drink.


Signs of dysphagia: what care staff should look for and report5

Initial signs of dysphagia include reduced chewing and behavioural problems affecting eating 6. Other symptoms of dysphagia include:

• food sticking in the throat; • coughing before, during or after swallowing; • choking on food or fluids; • nasal or oral regurgitation 7; • needing to swallow 3 or 4 times with each bolus; • frequently clearing the throat; • hoarse, breathy or wet-sounding voice; • drooling of food, fluid or saliva; • difficulty chewing or manipulating the bolus; • pooling of food in the mouth; • difficulty starting to swallow; • gurgly or ‘wet’ sounding respiration; • shortness of breath during meals; • protruding tongue movements; • increased time to finish a meal.

The ‘Supporting Information’ provides further information about dysphagia and aspiration.



References 1. American Medical Directors Association (AMDA). Altered nutritional status.

American Medical Directors Association (AMDA). Reviewed 2006. Available at: http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=3304&nbr=2530. Accessed 20th June, 2008.

2. Australian Government Department of Health and Ageing. Guidelines for a Palliative Approach in Residential Aged Care. Enhanced Version. Canberra: Australian Government Department of Health and Ageing; 2006. Report No: ISBN: 0 642 82939 X.

3. Bunny C, Bartl R. Best practice food and nutrition manual for aged care facilities : Addressing nutrition, hydration and catering issues Gosford NSW: Central Coast Health; 2004.

4. Archibald C. Promoting hydration in patients with dementia in healthcare settings. Nursing Standard. 2006;20(44):49-52.

5. White P. Swallowing and Dementia. Paper presented at: EACH Dementia Workshop, 2008; Auburn NSW.

6. Summersall J, Wight S. Chapter 10. When it's difficult to swallow: The role of the speech therapist. In: Hughes JC, ed. Palliative Care in Severe Dementia in association with Nursing and Residential Care. London: Quay Books; 2006.

7. Australian Society for Geriatric Medicine. Australian Society for Geriatric Medicine. Position Statement No. 12. Dysphagia and Aspiration in Older People. Australasian Journal on Ageing. 2004;23(4):198-202.

8. Watson R, Green SM, Legg L. The Edinburgh Feeding Evaluation in Dementia Scale #2 (EdFED #2): convergent and disciminant validity. Clinical Effectiveness in Nursing 2001;5(1):44-46.

9. Watson R, MacDonald J, McReady T. The Edinburgh Feeding Evaluation in Dementia Scale #2 (EdFED #2): inter- and intra-rater reliability. Clinical Effectiveness in Nursing. 2001;5(4):184-186.

http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=3304&nbr=2530

http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=3304&nbr=2530

Weight and BMI Monitoring (For resident’s weighing between 30kg and 100kg) (Place an x on the chart corresponding to the weight and BMI)

Weight on admission: ……………….. BMI on admission: ………………….. Height: ……………………………….

Weight Date:

100 Weight

95 (kg)

90

85

80

75

70

65

60

55

50

45

40

35

30

Body Mass Index (BMI) > 27 (state)

27 26 25 24 23 22 21 20 19 18 17 16 15 14

< 14 (state)

Add resident label here



Food and fluid intake chart Estimate the amount of food and fluid consumed at each meal and when snacks are offered. Date: ………………………… Amount consumed (circle)

Add resident label here

Fluid (ml) Breakfast ¼ ½ ¾ All

Cereal or porridge ¼ ½ ¾ All Fruit ¼ ½ ¾ All Yoghurt ¼ ½ ¾ All Bread or toast ¼ ½ ¾ All Eggs or other protein ¼ ½ ¾ All Tea, coffee, juice, milk drink, water (circle) ¼ ½ ¾ All Other (state): ¼ ½ ¾ All Comments:

Morning Tea Snack (state): ¼ ½ ¾ All Tea, coffee, juice, milk drink, water (circle) ¼ ½ ¾ All Other (state): ¼ ½ ¾ All Comments:

Lunch Soup ¼ ½ ¾ All Meat or other protein ¼ ½ ¾ All Vegetables ¼ ½ ¾ All Bread ¼ ½ ¾ All Butter or margarine ¼ ½ ¾ All Fruit ¼ ½ ¾ All Dessert ¼ ½ ¾ All Tea, coffee, juice, milk drink, water (circle) ¼ ½ ¾ All Other (state): ¼ ½ ¾ All Comments:

Afternoon Tea Snack (state): ¼ ½ ¾ All Tea, coffee, juice, milk drink, water (circle) ¼ ½ ¾ All Other (state): ¼ ½ ¾ All Comments:

Evening meal Soup ¼ ½ ¾ All Meat or other protein ¼ ½ ¾ All Vegetables ¼ ½ ¾ All Bread ¼ ½ ¾ All Butter or margarine ¼ ½ ¾ All Fruit ¼ ½ ¾ All Dessert ¼ ½ ¾ All Tea, coffee, juice, milk drink, water (circle) ¼ ½ ¾ All Other (state): ¼ ½ ¾ All Comments:

Supper Snack (state): ¼ ½ ¾ All Tea, coffee, juice, milk drink, water (circle) ¼ ½ ¾ All Other (state): ¼ ½ ¾ All Comments:

DecWeight Loss

ision-making frameworks in advanced dementia: Links to improved care project. of 52 Framework Guidelines.

Edinburgh Feeding Evaluation in Dementia Questionnaire (EdFED-Q)8, 9 Score answers to questions 1-10: never = 0; sometimes = 1; often = 2. 1. Does the patient require close supervision while feeding? __________ 2. Does the patient require physical help with feeding? __________ 3. Is there spillage while feeding? __________ 4. Does the patient tend to leave food on the plate at the end of a meal? __________ 5. Does the patient ever refuse to eat? __________ 6. Does the patient turn his head away while being fed? __________ 7. Does the patient refuse to open his mouth? __________ 8. Does the patient spit out his food? __________ 9. Does the patient leave his mouth open allowing food to drop out? __________ 10. Does the patient refuse to swallow? __________

Total score = ___________

(Total scores range from 0 to 20, with 20 being the most serious. Scores can be used to track change). 11. Indicate appropriate level of assistance required by patient: supportive-educative; partly compensatory; wholly compensatory

5% weight loss ready reckoner

resident starting weight (kg)

5% weight loss (kg)


5% weight loss (kg)


5% weight loss (kg)


5% weight loss (kg)


5% weight loss (kg)


5% weight loss (kg)

30.00 1.50 32.50 1.63 35.00 1.75 37.50 1.88 40.00 2.00 42.50 2.13 30.10 1.51 32.60 1.63 35.10 1.76 37.60 1.88 40.10 2.01 42.60 2.13 30.20 1.51 32.70 1.64 35.20 1.76 37.70 1.89 40.20 2.01 42.70 2.14 30.30 1.52 32.80 1.64 35.30 1.77 37.80 1.89 40.30 2.02 42.80 2.14 30.40 1.52 32.90 1.65 35.40 1.77 37.90 1.90 40.40 2.02 42.90 2.15 30.50 1.53 33.00 1.65 35.50 1.78 38.00 1.90 40.50 2.03 43.00 2.15 30.60 1.53 33.10 1.66 35.60 1.78 38.10 1.91 40.60 2.03 43.10 2.16 30.70 1.54 33.20 1.66 35.70 1.79 38.20 1.91 40.70 2.04 43.20 2.16 30.80 1.54 33.30 1.67 35.80 1.79 38.30 1.92 40.80 2.04 43.30 2.17 30.90 1.55 33.40 1.67 35.90 1.80 38.40 1.92 40.90 2.05 43.40 2.17 31.00 1.55 33.50 1.68 36.00 1.80 38.50 1.93 41.00 2.05 43.50 2.18 31.10 1.56 33.60 1.68 36.10 1.81 38.60 1.93 41.10 2.06 43.60 2.18 31.20 1.56 33.70 1.69 36.20 1.81 38.70 1.94 41.20 2.06 43.70 2.19 31.30 1.57 33.80 1.69 36.30 1.82 38.80 1.94 41.30 2.07 43.80 2.19 31.40 1.57 33.90 1.70 36.40 1.82 38.90 1.95 41.40 2.07 43.90 2.20 31.50 1.58 34.00 1.70 36.50 1.83 39.00 1.95 41.50 2.08 44.00 2.20 31.60 1.58 34.10 1.71 36.60 1.83 39.10 1.96 41.60 2.08 44.10 2.21 31.70 1.59 34.20 1.71 36.70 1.84 39.20 1.96 41.70 2.09 44.20 2.21 31.80 1.59 34.30 1.72 36.80 1.84 39.30 1.97 41.80 2.09 44.30 2.22 31.90 1.60 34.40 1.72 36.90 1.85 39.40 1.97 41.90 2.10 44.40 2.22

32.00 1.60 34.50 1.73 37.00 1.85 39.50 1.98 42.00 2.10 44.50 2.23 32.10 1.61 34.60 1.73 37.10 1.86 39.60 1.98 42.10 2.11 44.60 2.23 32.20 1.61 34.70 1.74 37.20 1.86 39.70 1.99 42.20 2.11 44.70 2.24 32.30 1.62 34.80 1.74 37.30 1.87 39.80 1.99 42.30 2.12 44.80 2.24

1.62 34.90 1.75 37.40 1.87 39.90 2.00 42.40 2.12 44.90 2.25 32.40



5% weight loss (kg)



5% weight loss (kg)


5% weight loss (kg)


5% weight loss (kg)

5% weight loss (kg)


5% weight loss (kg)

45.00 2.25 47.50 2.38 50.00 2.50 52.50 2.63 55.00 2.75 57.50 2.88 45.10 2.26 47.60 2.38 50.10 2.51 52.60 2.63 55.10 2.76 57.60 2.88 45.20 2.26 47.70 2.39 50.20 2.51 52.70 2.64 55.20 2.76 57.70 2.89 45.30 2.27 47.80 2.39 50.30 2.52 52.80 2.64 55.30 2.77 57.80 2.89 45.40 2.27 47.90 2.40 50.40 2.52 52.90 2.65 55.40 2.77 57.90 2.90 45.50 2.28 48.00 2.40 50.50 2.53 53.00 2.65 55.50 2.78 58.00 2.90 45.60 2.28 48.10 2.41 50.60 2.53 53.10 2.66 55.60 2.78 58.10 2.91 45.70 2.29 48.20 2.41 50.70 2.54 53.20 2.66 55.70 2.79 58.20 2.91 45.80 2.29 48.30 2.42 50.80 2.54 53.30 2.67 55.80 2.79 58.30 2.92 45.90 2.30 48.40 2.42 50.90 2.55 53.40 2.67 55.90 2.80 58.40 2.92 46.00 2.30 48.50 2.43 51.00 2.55 53.50 2.68 56.00 2.80 58.50 2.93 46.10 2.31 48.60 2.43 51.10 2.56 53.60 2.68 56.10 2.81 58.60 2.93 46.20 2.31 48.70 2.44 51.20 2.56 53.70 2.69 56.20 2.81 58.70 2.94 46.30 2.32 48.80 2.44 51.30 2.57 53.80 2.69 56.30 2.82 58.80 2.94 46.40 2.32 48.90 2.45 51.40 2.57 53.90 2.70 56.40 2.82 58.90 2.95 46.50 2.33 49.00 2.45 51.50 2.58 54.00 2.70 56.50 2.83 59.00 2.95 46.60 2.33 49.10 2.46 51.60 2.58 54.10 2.71 56.60 2.83 59.10 2.96 46.70 2.34 49.20 2.46 51.70 2.59 54.20 2.71 56.70 2.84 59.20 2.96 46.80 2.34 49.30 2.47 51.80 2.59 54.30 2.72 56.80 2.84 59.30 2.97 46.90 2.35 49.40 2.47 51.90 2.60 54.40 2.72 56.90 2.85 59.40 2.97 47.00 2.35 49.50 2.48 52.00 2.60 54.50 2.73 57.00 2.85 59.50 2.98 47.10 2.36 49.60 2.48 52.10 2.61 54.60 2.73 57.10 2.86 59.60 2.98 47.20 2.36 49.70 2.49 52.20 2.61 54.70 2.74 57.20 2.86 59.70 2.99 47.30 2.37 49.80 2.49 52.30 2.62 54.80 2.74 57.30 2.87 59.80 2.99 47.40 2.37 49.90 2.50 52.40 2.62 54.90 2.75 57.40 2.87 59.90 3.00



5% weight loss (kg)


5% weight loss (kg)


5% weight loss (kg)


5% weight loss (kg)


5% weight loss (kg)


5% weight loss (kg)

60.00 3.00 62.50 3.13 65.00 3.25 67.50 3.38 70.00 3.50 72.50 3.63 60.10 3.01 62.60 3.13 65.10 3.26 67.60 3.38 70.10 3.51 72.60 3.63 60.20 3.01 62.70 3.14 65.20 3.26 67.70 3.39 70.20 3.51 72.70 3.64 60.30 3.02 62.80 3.14 65.30 3.27 67.80 3.39 70.30 3.52 72.80 3.64 60.40 3.02 62.90 3.15 65.40 3.27 67.90 3.40 70.40 3.52 72.90 3.65 60.50 3.03 63.00 3.15 65.50 3.28 68.00 3.40 70.50 3.53 73.00 3.65 60.60 3.03 63.10 3.16 65.60 3.28 68.10 3.41 70.60 3.53 73.10 3.66 60.70 3.04 63.20 3.16 65.70 3.29 68.20 3.41 70.70 3.54 73.20 3.66 60.80 3.04 63.30 3.17 65.80 3.29 68.30 3.42 70.80 3.54 73.30 3.67 60.90 3.05 63.40 3.17 65.90 3.30 68.40 3.42 70.90 3.55 73.40 3.67 61.00 3.05 63.50 3.18 66.00 3.30 68.50 3.43 71.00 3.55 73.50 3.68 61.10 3.06 63.60 3.18 66.10 3.31 68.60 3.43 71.10 3.56 73.60 3.68 61.20 3.06 63.70 3.19 66.20 3.31 68.70 3.44 71.20 3.56 73.70 3.69 61.30 3.07 63.80 3.19 66.30 3.32 68.80 3.44 71.30 3.57 73.80 3.69 61.40 3.07 63.90 3.20 66.40 3.32 68.90 3.45 71.40 3.57 73.90 3.70 61.50 3.08 64.00 3.20 66.50 3.33 69.00 3.45 71.50 3.58 74.00 3.70 61.60 3.08 64.10 3.21 66.60 3.33 69.10 3.46 71.60 3.58 74.10 3.71 61.70 3.09 64.20 3.21 66.70 3.34 69.20 3.46 71.70 3.59 74.20 3.71 61.80 3.09 64.30 3.22 66.80 3.34 69.30 3.47 71.80 3.59 74.30 3.72 61.90 3.10 64.40 3.22 66.90 3.35 69.40 3.47 71.90 3.60 74.40 3.72

62.00 3.10 64.50 3.23 67.00 3.35 69.50 3.48 72.00 3.60 74.50 3.73 62.10 3.11 64.60 3.23 67.10 3.36 69.60 3.48 72.10 3.61 74.60 3.73 62.20 3.11 64.70 3.24 67.20 3.36 69.70 3.49 72.20 3.61 74.70 3.74 62.30 3.12 64.80 3.24 67.30 3.37 69.80 3.49 72.30 3.62 74.80 3.74 62.40 3.12 64.90 3.25 67.40 3.37 69.90 3.50 72.40 3.62 74.90 3.75



5% weight loss (kg)


5% weight loss (kg)


5% weight loss (kg)


5% weight loss (kg)


5% weight loss (kg)


5% weight loss (kg)

75.00 3.75 77.50 3.88 80.00 4.00 82.50 4.13 85.00 4.25 87.50 4.38 75.10 3.76 77.60 3.88 80.10 4.01 82.60 4.13 85.10 4.26 87.60 4.38 75.20 3.76 77.70 3.89 80.20 4.01 82.70 4.14 85.20 4.26 87.70 4.39 75.30 3.77 77.80 3.89 80.30 4.02 82.80 4.14 85.30 4.27 87.80 4.39 75.40 3.77 77.90 3.90 80.40 4.02 82.90 4.15 85.40 4.27 87.90 4.40 75.50 3.78 78.00 3.90 80.50 4.03 83.00 4.15 85.50 4.28 88.00 4.40 75.60 3.78 78.10 3.91 80.60 4.03 83.10 4.16 85.60 4.28 88.10 4.41 75.70 3.79 78.20 3.91 80.70 4.04 83.20 4.16 85.70 4.29 88.20 4.41 75.80 3.79 78.30 3.92 80.80 4.04 83.30 4.17 85.80 4.29 88.30 4.42 75.90 3.80 78.40 3.92 80.90 4.05 83.40 4.17 85.90 4.30 88.40 4.42 76.00 3.80 78.50 3.93 81.00 4.05 83.50 4.18 86.00 4.30 88.50 4.43 76.10 3.81 78.60 3.93 81.10 4.06 83.60 4.18 86.10 4.31 88.60 4.43 76.20 3.81 78.70 3.94 81.20 4.06 83.70 4.19 86.20 4.31 88.70 4.44 76.30 3.82 78.80 3.94 81.30 4.07 83.80 4.19 86.30 4.32 88.80 4.44 76.40 3.82 78.90 3.95 81.40 4.07 83.90 4.20 86.40 4.32 88.90 4.45 76.50 3.83 79.00 3.95 81.50 4.08 84.00 4.20 86.50 4.33 89.00 4.45 76.60 3.83 79.10 3.96 81.60 4.08 84.10 4.21 86.60 4.33 89.10 4.46 76.70 3.84 79.20 3.96 81.70 4.09 84.20 4.21 86.70 4.34 89.20 4.46 76.80 3.84 79.30 3.97 81.80 4.09 84.30 4.22 86.80 4.34 89.30 4.47 76.90 3.85 79.40 3.97 81.90 4.10 84.40 4.22 86.90 4.35 89.40 4.47 77.00 3.85 79.50 3.98 82.00 4.10 84.50 4.23 87.00 4.35 89.50 4.48 77.10 3.86 79.60 3.98 82.10 4.11 84.60 4.23 87.10 4.36 89.60 4.48 77.20 3.86 79.70 3.99 82.20 4.11 84.70 4.24 87.20 4.36 89.70 4.49 77.30 3.87 79.80 3.99 82.30 4.12 84.80 4.24 87.30 4.37 89.80 4.49 77.40 3.87 79.90 4.00 82.40 4.12 84.90 4.25 87.40 4.37 89.90 4.50



5% weight loss (kg)


5% weight loss (kg)


5% weight loss (kg)


5% weight loss (kg)


5% weight loss (kg)


5% weight loss (kg)

90.00 4.50 92.50 4.63 95.00 4.75 97.50 4.88 100.00 5.00 90.10 4.51 92.60 4.63 95.10 4.76 97.60 4.88 100.10 5.01 90.20 4.51 92.70 4.64 95.20 4.76 97.70 4.89 100.20 5.01 90.30 4.52 92.80 4.64 95.30 4.77 97.80 4.89 100.30 5.02 90.40 4.52 92.90 4.65 95.40 4.77 97.90 4.90 100.40 5.02 90.50 4.53 93.00 4.65 95.50 4.78 98.00 4.90 100.50 5.03 90.60 4.53 93.10 4.66 95.60 4.78 98.10 4.91 100.60 5.03 90.70 4.54 93.20 4.66 95.70 4.79 98.20 4.91 100.70 5.04 90.80 4.54 93.30 4.67 95.80 4.79 98.30 4.92 100.80 5.04 90.90 4.55 93.40 4.67 95.90 4.80 98.40 4.92 100.90 5.05 91.00 4.55 93.50 4.68 96.00 4.80 98.50 4.93 101.00 5.05 91.10 4.56 93.60 4.68 96.10 4.81 98.60 4.93 101.10 5.06 91.20 4.56 93.70 4.69 96.20 4.81 98.70 4.94 101.20 5.06 91.30 4.57 93.80 4.69 96.30 4.82 98.80 4.94 101.30 5.07 91.40 4.57 93.90 4.70 96.40 4.82 98.90 4.95 101.40 5.07 91.50 4.58 94.00 4.70 96.50 4.83 99.00 4.95 101.50 5.08 91.60 4.58 94.10 4.71 96.60 4.83 99.10 4.96 101.60 5.08 91.70 4.59 94.20 4.71 96.70 4.84 99.20 4.96 101.70 5.09 91.80 4.59 94.30 4.72 96.80 4.84 99.30 4.97 101.80 5.09 91.90 4.60 94.40 4.72 96.90 4.85 99.40 4.97 101.90 5.10

92.00 4.60 94.50 4.73 97.00 4.85 99.50 4.98 102.00 5.10 92.10 4.61 94.60 4.73 97.10 4.86 99.60 4.98 92.20 4.61 94.70 4.74 97.20 4.86 99.70 4.99 92.30 4.62 94.80 4.74 97.30 4.87 99.80 4.99 92.40 4.62 94.90 4.75 97.40 4.87 99.90 5.00


BMI calculator

To calculate the BMI: use the left-hand column to find the resident's height in cm. Move horizontally across the row until you find the weight nearest to the resident's current weight. The BMI on the top of that column is the resident's approximate BMI. For example, a resident is 1.72m tall, and weighs 54.1kg. The BMI is between 18 and 19. Height

Height in sq cm

Weight in kilograms if BMI is:

cm ft BMI 16

BMI 17

BMI 18

BMI 19

BMI 20

BMI 21

BMI 22

BMI 23

BMI 24

BMI 25

BMI 26

BMI 27

1.40 4,7 1.96 31.4 33.3 35.3 37.2 39.2 41.2 43.1 45.1 47.0 49.0 51.0 52.9 1.41 1.99 31.8 33.8 35.8 37.8 39.8 41.8 43.7 45.7 47.7 49.7 51.7 53.7 1.42 4,8 2.02 32.3 34.3 36.3 38.3 40.3 42.3 44.4 46.4 48.4 50.4 52.4 54.4 1.43 2.04 32.7 34.8 36.8 38.9 40.9 42.9 45.0 47.0 49.1 51.1 53.2 55.2 1.44 4,9 2.07 33.2 35.3 37.3 39.4 41.5 43.5 45.6 47.7 49.8 51.8 53.9 56.0 1.45 2.10 33.6 35.7 37.8 39.9 42.1 44.2 46.3 48.4 50.5 52.6 54.7 56.8 1.46 4,9.5 2.13 34.1 36.2 38.4 40.5 42.6 44.8 46.9 49.0 51.2 53.3 55.4 57.6 1.47 2.16 34.6 36.7 38.9 41.1 43.2 45.4 47.5 49.7 51.9 54.0 56.2 58.3 1.48 4,10 2.19 35.0 37.2 39.4 41.6 43.8 46.0 48.2 50.4 52.6 54.8 57.0 59.1 1.49 2.22 35.5 37.7 40.0 42.2 44.4 46.6 48.8 51.1 53.3 55.5 57.7 59.9 1.50 4,11, 2.25 36.0 38.3 40.5 42.8 45.0 47.3 49.5 51.8 54.0 56.3 58.5 60.8 1.51 2.28 36.5 38.8 41.0 43.3 45.6 47.9 50.2 52.4 54.7 57.0 59.3 61.6 1.52 5,0 2.31 37.0 39.3 41.6 43.9 46.2 48.5 50.8 53.1 55.4 57.8 60.1 62.4 1.53 2.34 37.5 39.8 42.1 44.5 46.8 49.2 51.5 53.8 56.2 58.5 60.9 63.2 1.54 5,0.5 2.37 37.9 40.3 42.7 45.1 47.4 49.8 52.2 54.5 56.9 59.3 61.7 64.0 1.55 2.40 38.4 40.8 43.2 45.6 48.1 50.5 52.9 55.3 57.7 60.1 62.5 64.9 1.56 5,1.5 2.43 38.9 41.4 43.8 46.2 48.7 51.1 53.5 56.0 58.4 60.8 63.3 65.7 1.57 2.46 39.4 41.9 44.4 46.8 49.3 51.8 54.2 56.7 59.2 61.6 64.1 66.6 1.58 5,2 2.50 39.9 42.4 44.9 47.4 49.9 52.4 54.9 57.4 59.9 62.4 64.9 67.4 1.59 2.53 40.4 43.0 45.5 48.0 50.6 53.1 55.6 58.1 60.7 63.2 65.7 68.3 1.60 5,3 2.56 41.0 43.5 46.1 48.6 51.2 53.8 56.3 58.9 61.4 64.0 66.6 69.1 1.61 2.59 41.5 44.1 46.7 49.2 51.8 54.4 57.0 59.6 62.2 64.8 67.4 70.0 1.62 5,4 2.62 42.0 44.6 47.2 49.9 52.5 55.1 57.7 60.4 63.0 65.6 68.2 70.9 1.63 2.66 42.5 45.2 47.8 50.5 53.1 55.8 58.5 61.1 63.8 66.4 69.1 71.7 1.64 5,4.5 2.69 43.0 45.7 48.4 51.1 53.8 56.5 59.2 61.9 64.6 67.2 69.9 72.6


Height

Height in sq cm

Weight in kilograms if BMI is:

cm ft BMI 16

BMI 17

BMI 18

BMI 19

BMI 20

BMI 21

BMI 22

BMI 23

BMI 24

BMI 25

BMI 26

BMI 27

1.65 2.72 43.6 46.3 49.0 51.7 54.5 57.2 59.9 62.6 65.3 68.1 70.8 73.5 1.66 5,5 2.76 44.1 46.8 49.6 52.4 55.1 57.9 60.6 63.4 66.1 68.9 71.6 74.4 1.67 2.79 44.6 47.4 50.2 53.0 55.8 58.6 61.4 64.1 66.9 69.7 72.5 75.3 1.68 5,6 2.82 45.2 48.0 50.8 53.6 56.4 59.3 62.1 64.9 67.7 70.6 73.4 76.2 1.69 2.86 45.7 48.6 51.4 54.3 57.1 60.0 62.8 65.7 68.5 71.4 74.3 77.1 1.70 5,7 2.89 46.2 49.1 52.0 54.9 57.8 60.7 63.6 66.5 69.4 72.3 75.1 78.0 1.71 2.92 46.8 49.7 52.6 55.6 58.5 61.4 64.3 67.3 70.2 73.1 76.0 79.0 1.72 5,8 2.96 47.3 50.3 53.3 56.2 59.2 62.1 65.1 68.0 71.0 74.0 76.9 79.9 1.73 2.99 47.9 50.9 53.9 56.9 59.9 62.9 65.8 68.8 71.8 74.8 77.8 80.8 1.74 5,8.5 3.03 48.4 51.5 54.5 57.5 60.6 63.6 66.6 69.6 72.7 75.7 78.7 81.7 1.75 3.06 49.0 52.1 55.1 58.2 61.3 64.3 67.4 70.4 73.5 76.6 79.6 82.7 1.76 5,9 3.10 49.6 52.7 55.8 58.9 62.0 65.0 68.1 71.2 74.3 77.4 80.5 83.6 1.77 3.13 50.1 53.3 56.4 59.5 62.7 65.8 68.9 72.1 75.2 78.3 81.5 84.6 1.78 5,10 3.17 50.7 53.9 57.0 60.2 63.4 66.5 69.7 72.9 76.0 79.2 82.4 85.5 1.79 3.20 51.3 54.5 57.7 60.9 64.1 67.3 70.5 73.7 76.9 80.1 83.3 86.5 1.80 5,11 3.24 51.8 55.1 58.3 61.6 64.8 68.0 71.3 74.5 77.8 81.0 84.2 87.5 1.81 3.28 52.4 55.7 59.0 62.2 65.5 68.8 72.1 75.4 78.6 81.9 85.2 88.5 1.82 5,11.5 3.31 53.0 56.3 59.6 62.9 66.2 69.6 72.9 76.2 79.5 82.8 86.1 89.4 1.83 3.35 53.6 56.9 60.3 63.6 67.0 70.3 73.7 77.0 80.4 83.7 87.1 90.4 1.84 6,0.5 3.39 54.2 57.6 60.9 64.3 67.7 71.1 74.5 77.9 81.3 84.6 88.0 91.4 1.85 3.42 54.8 58.2 61.6 65.0 68.5 71.9 75.3 78.7 82.1 85.6 89.0 92.4 1.86 6,1 3.46 55.4 58.8 62.3 65.7 69.2 72.7 76.1 79.6 83.0 86.5 89.9 93.4 1.87 3.50 56.0 59.4 62.9 66.4 69.9 73.4 76.9 80.4 83.9 87.4 90.9 94.4 1.88 6,2 3.53 56.6 60.1 63.6 67.2 70.7 74.2 77.8 81.3 84.8 88.4 91.9 95.4 1.89 3.57 57.2 60.7 64.3 67.9 71.4 75.0 78.6 82.2 85.7 89.3 92.9 96.4 1.90 6,3 3.61 57.8 61.4 65.0 68.6 72.2 75.8 79.4 83.0 86.6 90.3 93.9 97.5 1.91 3.65 58.4 62.0 65.7 69.3 73.0 76.6 80.3 83.9 87.6 91.2 94.9 98.5 1.92 6,3.5 3.69 59.0 62.7 66.4 70.0 73.7 77.4 81.1 84.8 88.5 92.2 95.8 99.5 1.93 3.72 59.6 63.3 67.0 70.8 74.5 78.2 81.9 85.7 89.4 93.1 96.8 100.6 1.94 6,4 3.76 60.2 64.0 67.7 71.5 75.3 79.0 82.8 86.6 90.3 94.1 97.9 101.6


Tasks relating to the goals of care associated with weight loss in advanced dementia (MMSE < 10) Talk to the resident if possible, the person responsible, and family members about the goals of care for the resident. Is the resident to receive: · active interventions, when you will look for and treat the causes of weight loss; · a palliative approach, where you may treat some reversible causes of weight loss, and otherwise be working towards improving the resident’s comfort, and address their psychological, social and spiritual needs; or · end of life (terminal) care, when death is likely to occur in the next days or weeks, and you will focus on resident comfort, and emotional support to the family members.

Issue / Task Goals of care relating to weight loss

for a resident with advanced dementia

Active

intervention Palliative Approach

End of life (terminal) care

Daily food and fluid provision Develop a nutrition care plan based on the goals of care for the resident yes yes Provide food that the resident likes yes yes Provide fluids that the resident likes yes yes Assist the resident to eat the meal if required yes yes Provide an environment conducive to eating: relaxing, low stimulus, pleasant smells yes yes Make sure the resident has sufficient time and help to eat yes yes Make sure assistance to feed is given with the carer seated at eye level to improve his/her social well-being

yes yes

Establish a relationship with the resident before feeding yes yes Position the resident so he/she can eat without choking yes yes Provide finger foods so the resident can feed him/herself to maintain independence yes yes Provide feeding aids so the resident can feed him/herself to maintain independence yes yes Provide meals and fluids of a suitable texture for the resident’s swallowing ability yes yes

Resident needs to be assessed at least daily by an RN to see whether he/she is conscious enough to offer food. If yes, then continue. If unable to swallow, then mouth care only.


Issue / Task

Goals of care relating to weight loss for a resident with advanced

dementia

Active intervention

Palliative Approach


Assess the resident’s ability to self feed regularly yes yes No. Provide full assistance

Assess for common feeding problems in advanced dementia yes yes No.

Encourage the resident to eat and drink, verbally prompt No, offer food if RN assesses able to swallow, sips fluid, ice chips, oral hygiene.

Yes, but do not force the resident to eat. Food should be encouraged for comfort and enjoyment

yes

Daily mouth care Give frequent small sips of fluid to reduce the sensation of thirst No. encourage

fluid intake No. encourage fluid intake

May only require mouth care. RN to assess

Clean mouth by rinsing the mouth with water and clean teeth with a soft toothbrush and toothpaste

yes yes Yes if tolerated

Monitor and observe for weight loss Review the history of weight loss and appetite changes Yes Yes no

Weigh the resident monthly. If weight loss interventions start, then weigh weekly until stable or goals of care change

yes no

Assess the resident for undernutrition using the MNA yes no

Measure the resident’s height; calculate his/her BMI every time the resident is weighed

yes

Yes, unless the decision is made and documented that weight will not be monitored

no

If weight loss is noted: assess and manage common problems Is sufficient assistance and time provided to the resident to encourage eating? yes yes No, offer food


Issue / Task


dementia

Active intervention

Palliative Approach


Have the resident’s preferences for food changed eg likes more sweet foods; or more savoury; can the food be more culturally appropriate? Individualise the nutrition care plan; refer to a dietitian if necessary

yes yes if RN assesses able to swallow, sips fluid, ice chips, oral hygiene.

Improve the nutritional content of food to try to prevent or reduce the amount of weight loss

yes yes No. give the resident whatever he/she likes

Is the environment too overstimulating or is the resident socially isolated at mealtimes? are there other factors in the environment affecting food intake? Change the disrupting factor.

yes Yes yes

Check the mouth for dental problems, refer to a dentist if necessary yes yes no

Assess for swallowing difficulties, refer to a speech pathologist, change the texture of the diet & fluids if necessary and/or the position of the resident for feeding

yes yes no

Re-weigh to validate previous measurement yes no

Talk to care staff and family members to see if weight loss is really unintended or unexpected

yes no

Record the food intake for 1-3 days to establish how much food is being eaten yes no

Review the current diet: is the resident receiving enough energy to compensate for behaviours such as pacing?

yes

Yes, unless the decision is made and documented that weight will not be monitored

no

Review the use of any therapeutic diets: should they be cancelled?

Yes. Cancel therapeutic diets eg low salt, low cholesterol, offer food the resident likes

No. Therapeutic diet should continue unless the goals of care change and are documented

Yes. Cancel all therapeutic diets, offer food the resident likes


Issue / Task


dementia

Active intervention

Palliative Approach


If weight loss is noted: assess / screen for and treat potentially reversible medical conditions Assess the resident for constipation and treat if present yes Yes Yes, if

symptomatic. Look for restlessness, agitation, vomiting

Assess for pain and treat if present yes yes Yes, if symptomatic. Look for restlessness, agitation

Assess the resident for depression. Use a valid / reliable tool such as the Cornell Scale for Depression in Dementia to assess. Treat if depression present.

Yes Yes no

Review all medications and change those that affect weight loss

Yes Yes. Stop any medications that can be stopped

Yes. Stop any medications that are not for comfort only

Undertake pathology tests to screen for metabolic causes of weight loss eg hyperthyroidism

yes Yes, unless the decision is made and documented that pathology tests will not occur

no

Screen for chronic infections: pathology tests; urine cultures; chest X-Ray Yes Yes, unless a decision is made and documented

no


Issue / Task


dementia

Active intervention

Palliative Approach


that diagnostic tests will not occur

Treat nausea, vomiting and diarrhoea if present yes yes Yes. Aim to provide maximum comfort

Undertake pathology tests including therapeutic levels of drugs; full blood count; liver enzymes; total protein & albumin; thyroid function tests; fasting BSL; B12 levels

yes Yes, unless the decision is made and documented that pathology tests will not occur

no

Screen for urinary tract infection: do a urinalysis for albumin yes yes no

Undertake diagnostic tests to screen for or diagnose causes of weight loss, including lactose intolerance, malabsorption, dumping syndrome

yes Yes, unless there is a directive that no screening tests for weight loss are to be done

no

Assess for irreversible causes of weight loss Review for increased metabolic need causing weight loss due to persistent infections, large pressure sores, dementia progression, co-morbid conditions such as heart failure or cancer Ask GP to undertake a physical assessment for cachexia

Yes, if the person responsible insists despite discussing the appropriateness of changing the goals of care

No No


Issue / Task


dementia

Active intervention

Palliative Approach


Consider nutritional support No. Diligent

hand-feeding is best practice

Yes, if the benefits outweigh the burdens in the individual case. If weight loss irreversible then no.

Consider the benefits and burdens for the resident in commencing PEG feeding, and commence PEG feeds.

No.

Discontinue PEG feeding

No, unless the resident’s ability to take oral food & fluids has improved, or the goals of care have changed

Yes, if symptoms such as vomiting occur then reducing the flow or ceasing feeds should be considered.

Trial single nutrients or liquid meal replacements for nutritional support

No. An individualised nutrition plan with foods the resident likes that are enriched to promote weight gain is best practice

No. An individualised nutrition plan with foods the resident likes that are enriched is to promote weight gain best practice

Only as a total food, NOT as a supplement to regular food.

Provide information and support to person responsible +/- family members Review the stage of dementia with person responsible as part of the conversations about the goals of care

yes yes no

Discuss the issues of feeding with the person responsible and family members on admission and throughout the time the resident is in the facility

yes yes yes



Issue / Task


dementia

Active intervention

Palliative Approach


Provide emotional support to the person responsible and family members relating to feeding issues throughout the time the resident is in the facility

yes yes yes

Discuss the benefits and burdens of tube feeding with the person responsible and family members

yes yes yes

Hold a family conference to discuss feeding issues and weight loss Yes Yes no


ACKNOWLEDGEMENTS This project was funded by a Local Palliative Care Grant (Round 3: Care planning) by the Australian Government Department of Health and Ageing.

Contribution list: Working Party members: Christine Ryan Clinical Nurse Consultant Palliative Care: Lead Clinician

Primary Care & Community Health Network, Sydney West Area Health Service (SWAHS)

Therese Smeal Clinical Nurse Consultant Palliative Care Primary Care & Community Health Network, SWAHS

Rose Xuereb Clinical Nurse Consultant Aged Care Primary Care & Community Health Network, SWAHS

Robyn Maxwell Clinical Nurse Consultant Palliative Care Primary Care & Community Health Network, SWAHS

Jo Lewis Clinical Nurse Consultant Palliative Care Mount Druitt Palliative Care Unit, SWAHS

Sally Easterbrook Project Officer Primary Care & Community Health Network, SWAHS

Roderick Pirotta Clinical Nurse Consultant Dementia Care Primary Care & Community Health Network, SWAHS

Deborah Maclaren Clinical Nurse Consultant Palliative Care Primary Care & Community Health Network, SWAHS

Circulated to the following individuals for comment: Dr Michael Noel Director, Palliative Care Service, Nepean Cancer Network, SWAHS Dr Phillip Lee Palliative Care, Westmead Hospital Dr Heather Stewart General Practitioner, Blue Mountains Dr Margaret McGarritty

Staff Specialist, St Joseph’s Hospital Auburn, SWAHS

Dr Gary Cheuk Medical Director, BMDH Rehabilitation and Aged Care Services, Blacktown Hospital Campus, SWAHS

Ms Alison Blakey CNC Aged Care, Lawson Community Health Centre, SWAHS Ms Jennifer McQueen Community Dietitian, Mt Druitt CHC, SWAHS Ms Penny White Senior Speech Pathologist, OPERA, Westmead Hospital Campus Ms Robyn Rance NUM, Wards 1 & 2, Governor Phillip Nursing Home, Penrith Ms Carolyn Fularon Executive Care Manager, Minchinbury Manor Ms Jenny Le Miere Director of Nursing, Our Lady of Consolation Aged Care Facility, Rooty Hill Ms Sue Briggs Clinical Nurse Consultant Quality Improvement, Primary Care & Community

Health Network, SWAHS Ms Carol Denne Nursing Education Coordinator, Primary Care & Community Health Network,

SWAHS

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