Rose Sino sits in her wheelchair as lunch is placed before her. Her son offers her a forkful of cheese blintz, which Sino quickly chews before accepting another bite.
While this scene might appear routine, its significance is not lost on her son, David Swartz, or her caregivers at the Jewish Home for the Aging of Greater Los Angeles (JHA). Sino, 88, is a resident of JHA's Goldenberg-Ziman Special Care Center, a facility that serves elderly residents with dementia. Five years ago, Sino lost all interest in eating and required a feeding tube to get sufficient nutrition.
For Sino and many other frail, elderly nursing home residents, lack of appetite is a common problem, one which can lead to a rapid decline in health, said Dr. John Schnelle, director of the Anna and Harry Borun Center for Gerontological Research.
Weight-loss prevention is one of the principal areas of investigation at the Borun Center, a joint venture between JHA and UCLA's David Geffen School of Medicine. Housed on the JHA campus in Reseda, the center was established in 1989 to identify and test nonmedical measures that could improve daily care and quality of life for nursing home residents. Given that the number of people 85 years or older is expected to almost double in 25 years, the center's research is of growing interest to the government, private industry and the public.
While the Borun Center utilizes JHA to test and pilot numerous interventions, it also conducts research at facilities throughout the country. In addition to preventing weight loss, current projects focus on preventing mobility decline, detecting pain, preventing pressure ulcers and managing incontinence.
The center has used research findings to develop protocols, available on its Web site, for use by nursing homes. The strategies focus on everyday routines, rather than on medical interventions.
"Once a person is frail enough to enter a long-term care facility, they're usually taking five to six medications," Schnelle said. "They are less inclined to do surgical or pharmacological interventions. What they want is for their pain to be managed and their incontinence taken care of and for staff to treat them in a reasonable way."
The Borun Center is currently working with the federal government's Center for Medicare and Medicaid Services to improve methods of evaluating nursing home care. Current methods don't always provide the most reliable information, according to Schnelle. Not only are the elderly less likely to complain, he said, but the phrasing of questions can influence their responses.
"Asking, 'Are you satisfied with how often you are taken to the bathroom?' will typically generate a yes response, even if that is not the case," he explained. "Asking, 'How many times would you like to be helped to go to the bathroom?' and 'How many times are you taken to the bathroom?' is more likely to reveal the discrepancy between what residents want and what they get," he noted.
Schnelle said that most nursing homes are understaffed and that in the typical facility, residents are taken to the bathroom only once a day. (He also said that, in all measures the center looks at, JHA exceeded all other facilities studied.)
The Borun Center's nutrition and weight-loss study at JHA identifies strategies to prevent the decrease in eating and fluid intake common to nursing home residents. Schnelle cited depression and appetite change as two principal causes.
"Food doesn't taste as good, and they simply don't care as much about it as they once did.... But you can reverse the decline if meal time becomes social."
Sino's improved eating came about not because of a change in her food, but in how it was presented and served. Using Borun Center study results, JHA's Special Care Center systematically incorporated eight measures -- including greeting residents by name and providing verbal encouragement -- which had been shown to boost caloric intake among certain residents by about 300 calories a day.
"At some facilities, a food tray is placed in front of the resident, and that's it," said Susan Leitch, community manager for the Goldenberg-Ziman Building.
In her facility, servers take plates off the serving tray and place them, restaurant style, before the residents. Containers are opened and meat is cut for those who require assistance. Residents are greeted by name and offered substitutions for foods they dislike.
Nursing aides and other staff sit with residents or stop by their tables with encouragement. "Try this. This is good," one says. "I know you like chocolate," says another as she presents a bowl of ice cream to a resident.
In addition, snacks are incorporated into activities as a way to boost caloric intake, and family members are encouraged to bring treats that they know their relative enjoys. Sino, for example, ate the pieces of chocolate her son offered her, even when she was still using the feeding tube. He credits the chocolate with renewing her interest in eating.
Not surprisingly, the interventions identified by the Borun Center require greater staff time. That means higher costs.
Molly Forrest, JHA's CEO, acknowledged that those costs present a challenge. Approximately 80 percent of JHA residents are on Medi-Cal, and the reimbursement received does not cover the expenses incurred.
"Quality is a costly item," Forrest said. "The needs are so great, and those needs can only be met by the hands of a caregiver."
Schnelle suspects these interventions also prevent hospitalization and prolong life. But even if they did not improve clinical outcomes, he believes improving quality of life for the frail elderly is justified from a moral point of view.
"I think we have to be very clear about the staffing requirements needed to provide good care and let people make choices," he said.
For David Swartz, the choice is clear. Sitting with his mother at lunchtime, he beams. By the time she's done, only one tiny bite of blintz remains on her plate.
For more information, visit www.borun.medsch.ucla.edu.
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