Chapter 6 Nutrition Assessment of Older Adults

This method is the least accurate and should not be used with individuals who have musculoskeletal defor- mities or contractures.

Weight

The ambulatory client should be weighed on the same scale each time. Scales provide a measure of weight change, but the number recorded is only one piece of the necessary data. Facilities need to establish a weight protocol that sets baseline parameters for weighing individuals at admission with routine weights to follow. It is suggested the person be weighed with minimum clothing and no shoes prior to breakfast. Newly admitted individuals should be weighed weekly for the first four weeks and, if stable, may then be weighed monthly. Some facilities prefer to continue to weigh residents weekly, especially for those at risk for weight loss.

If the nonambulatory client can sit, a movable wheelchair balance or a wheelchair scale is used. The total weight minus the weight of the wheelchair equals the weight of the client. Bed scales or patient lifts with a scale should be used for weighing bedfast clients.

The Centers for Medicare & Medicaid Services (CMS) is now allowing self-reporting of weights from hospitals or physicians’ offices as a basis for determin- ing percentage of weight loss for new admissions; however, accuracy may become an issue in these instances and could lead to increased percentages in Certification and Survey Provider Enhanced Reports and Quality Indicator Reports. Best practice dictates an accurate in-house weight be taken within 24 hours of admission. If the weight is obtained elsewhere, the source should be documented in the medical record. To obtain an accurate standing weight, the RDN should work with nursing to ensure the designated staff:

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has been trained and is familiar with the use of the instrument;

● ● calibrate the scale to zero;

weigh the client at the same time of day on the routine schedule and, if possible, by the same caregiver;

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weigh the client nude or in light underclothing, without shoes;

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position the client’s feet over the center of the platform;

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adjust the weights on the balance beam, then read and accurately record measurement to the nearest 0.25 lb (on a digital scale, the reading should be to the nearest tenth of a kg or lb); and

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compare present measurement with previous weight measurement(s) and with reference tables or graphs to determine change and to aid with interpretation of measurements.

Suggestions for an accurate seated or prone measure- ment are as follows:

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For chair scale, position subject upright in center of chair, leaning on backrest.

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Weigh client and wheelchair, then weigh the wheelchair alone and subtract that weight.

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For bed scale, position subject comfortably in center of sling.

A second measurement using either method must be taken to verify accuracy of weight. Frequent checking and adjustment of the zero weight on the scale’s hori- zontal beam are necessary to ensure accuracy. The main and fractional sliding weights should be placed at their respective zero positions, and the zeroing weight should then be checked with a set of standard weights monthly and by a dealer of weights and measures at least two or three times a year. Accurate weights are critical for the RDN when evaluating a client’s nutri- tional status. Weight can be estimated by using recumbent mea- surements of arm and calf circumferences, subscapular skinfold thickness, and knee height, although these are seldom used in the long-term care arena (35).

Body Mass Index

Body composition measures may be ineffective in the older adult; in fact, some assessment measures are not necessarily accurate or feasible to use with older adults (36). Body mass index (BMI) is a weight-to-height ratio composed of body weight (in kilograms) divided by the square of the height in meters. BMI does not reflect the body composition (fat and muscle mass), and like weight, it can be unreliable in the presence of confound- ing factors such as edema or ascites and may be one such measurement. BMI does not consider the variable height loss with age. Thus, if height decreases while weight remains stable, an individual’s BMI increases, which may not be a true indication of nutritional status. The National Quality Forum (NQF #0421): Preventive Care and Screening: Body Mass Index Screening Measure and Follow-Up Plan suggests that normal BMI parameters for age 65 years and older be between 23 and 30 (37).

In a study of seriously ill, hospitalized stroke patients, baseline measures of nutritional status, includ- ing BMI (less than 20), were lower for those who died or remained in the hospital than for those who were dis- charged (38). A US multicenter study examining the relationship of BMI to subsequent mortality among