You are asked to see Mr.

Basset, who is 80 years old, currently living alone, and has recently lost his

wife. His children do not live nearby, but Mr. Basset sees them on holidays. Mr. Basset was recently

diagnosed with lung cancer and has had an unexplained weight loss of 20 pounds in 3 months. He is

getting chemotherapy as well as taking oral medication for hypertension and arthritis, and is showing

signs of dehydration.

Mr. Basset reports that his wife did most of the cooking and he has limited cooking skills. He usually has

cereal with milk and coffee for breakfast and soup for a second meal later in the day. He eats crackers

throughout the day if he is hungry, but admits that he doesn’t have much of an appetite. In addition, Mr.

Basset has ill-fitting dentures and claims that food just does not taste the same. He is also on a limited

budget.

1. What physiological factors might contribute to Mr. Basset’s weight loss?

 Elevated concentrations of tumor necrosis factor a

 Decrease of lean body mass that occurs naturally with age

 Lack of intake, due to Ms. Basset no longer being there to cook

 He fills up on foods that are not nutritious or caloric enough to maintain weight

2.  What psychosocial factors might contribute to Mr. Basset’s weight loss?

 Depression

 Ill-fitting dentures make eating unenjoyable

 Limited budget to buy food

3.   Give one likely explanation why Mr. Basset’s dentures do not fit.
  They may be new and he has not adjusted

 Improper denture care may have caused the dentures to lose shape

 Aging and weight fluctuations can change the fit of the dentures. Mr. Basset’s mouth

may have changed.

4.   What nursing actions need to be included in the plan of care to improve Mr. Basset’s nutritional

status?

Treatment depends on the underlying cause, so Mr. Basset needs to be thoroughly assessed to

find the cause of his weight loss. He should begin taking nutritional supplements while he is undergoing

other treatments for this issue.

Dietary changes that incorporate his taste preferences, flavor enhancers that help food taste

better, softer foods that may be more comfortable to chew, or enlisting the help of someone to assist

him in eating or to provide him company while he eats are some possible non-pharmacological

interventions that may result in higher food consumption.

If these methods prove ineffective, there are medications that will increase appetite. Megastrol,

mirtazapine, cyproheptadine, and dronabinol, and human growth hormone have all proven helpful in

increasing appetite. If Mr. Barrow is in a state that allows the use of medical marijuana, that is also an

option. Studies have shown that the use of medical marijuana can not only increase appetite, but may

shrink cancer cells and limit the inflammation associated with arthritis. However, it should be made clear

to Mr. Barrows that these are limited studies and this research, while exciting, has not been widely

accepted by the medical community. It should also be pointed out that all medications, even so-called

natural ones, have side effects that may not be conducive to increased health or a higher standard of

living. The choice of which pharmacological methods to pursue would have to be Mr. Barrow’s choice

once he is fully educated on the pros and cons of each medication.

 If the cause is a lack of funding, there are programs that may be available to help ensure that he

has access to healthy meals, such as meals on wheels and church and government groups. He should be

referred to a social worker or case manager to ensure that he is given access to all the resources

available to him.

If the cause lies with his ill-fitting dentures, he should be referred to an appropriate dental

professional to get new dentures.

If depression is the cause, he should be referred to a mental health specialist while he is

pursuing medical treatment.

The issue of weight loss in the elderly is usually a multifactorial issue that requires many

disciplines, such as dietitians, social workers, dental professionals, home health aides, case managers,

nurses, mental health professionals, and various physicians, to treat effectively. Depending on the cause

of his weight loss, there is a good chance that at least of these 4 specialists will need to be involved in his

treatment before Mr. Barrows will be able to turn his attention to his other health needs.

References

The Administration for Community Living. (2016, August 8). Nutrition Services. Retrieved from

http://www.aoa.acl.gov/AoA_Programs/HPW/Nutrition_Services/index.aspx

American Dental Association, & American College of Prosthodontists. (2016). American Dental

Association - Removable Partial Dentures. Retrieved from

http://www.mouthhealthy.org/en/az-topics/d/dentures-partial

Americans for Safe Access. (2016). Aging & Medical Marijuana - Americans for Safe Access.

Retrieved from http://www.safeaccessnow.org/aging_booklet#research

Evans, C. (2005). Malnutrition in the Elderly: A Multifactorial Failure to Thrive. The Permanente

Journal, 9(3). doi:10.7812/tpp/05-056

Gaddey, H., & Holder, K. (2014). Unintentional Weight Loss in Older Adults. American Family

Physician, 89(9), 718-722.

Grodner, M., Roth, S. L., Walkingshaw, B. C., & Grodner, M. (2012). Nutritional foundations and

clinical applications: A nursing approach (6th ed.). St. Louis, MO: Mosby/Elsevier.

Meals on Wheels America. (2016). Retrieved from http://www.mealsonwheelsamerica.org/?

gclid=Cj0KEQjwyJi_BRDLusby7_S7z-

IBEiQAwCVvn9Fjhgepndxn8rLa8hVi8JXLTucGvS6OLyb5KspNlFEaAqhd8P8HAQ

Moriguti, J. C., Moriguti, E. K., Ferriolli, E., Cação, J. D., Iucif Junior, N., & Marchini, J. S. (2001).

Involuntary weight loss in elderly individuals: assessment and treatment. Sao Paulo Medical

Journal, 119(2). doi:10.1590/s1516-31802001000200007

When I did my post, I talked a little about tumor necrosis, but I only discussed the

chemotherapeutic side effect of anorexia.  I never discussed nausea or vomiting, which, as you

pointed out, can also be a reason for weight loss.  In fact, he does say that he often eats only

saltines, which is possibly a clue that nausea is a daily issue for him.  A couple of the

medications that I mentioned will also work for nausea and vomiting such as dronabinol and

medical marijuana.  Other pharmacological treatment possibilities might be ondansetron,

promethazine, lorazepam, metroclopramide, or aprepitant.  There are far more medications than

this.  It is the job of the physician working with the patient to decide which of the many available

options might work best for Mr. Barrows.

 To help with nausea and vomiting, there are also non-pharmacological interventions that

nurses can initiate as part of our nursing care.   We can encourage fluids to help prevent

dehydration, while telling him to avoid liquids at meal time so that all the possible nutrients from

the meal are more likely to be consumed.  We should also encourage him to eat small amounts of

food throughout the day and to eat on a schedule, instead of when he is hungry.  This will make

sure that he gets the necessary nutrients and calories, while preventing the possibility of

overeating at meal time because he is very hungry, which can distend the stomach and cause

nausea.  He may already know this, but he should be encouraged to eat dry foods, like crackers. 

What he may not know is that other dry foods like fortified cereals or toast can provide the same

benefits while supplying more nutrients since they are fortified with vitamins and minerals,

unlike saltines.  He should avoid strong odors and spicy food, which can cause an

overproduction of stomach acids and intensify nausea and vomiting.  He should be taught to

remain upright for at least 2 hours after eating so that his food doesn't cause gastric reflux or

heartburn.  Though it may seem counterintuitive, Mr. Barrows should be encouraged to refrain

from eating his favorite foods during this time because it can psychologically cause him to

associate them with nausea and vomiting and he will no longer be able to enjoy them when his

disease process is resolved.  Mr. Barrow should be encouraged to carry hard candies or suckers

with him so that he can suck on them if he becomes nauseous, which may alleviate the symptoms

some. 

Nausea and vomiting are a very common cause of anorexia and, subsequently, weight

loss, but there are many simple, non-pharmacological ways to alleviate this issue.  In fact, if this

is his main issue, it might be the easiest of the possibilities to treat. 

Good job pointing out this possibility.

 References

Cleveland Clinic. (2016). Nausea, Vomiting & Chemotherapy - Managing Side Effects -

Chemocare. Retrieved from http://chemocare.com/chemotherapy/side-effects/nausea-

vomiting-chemotherapy.aspx

Gaddey, H., & Holder, K. (2014). Unintentional Weight Loss in Older Adults. American

Family Physician, 89(9), 718-722.

Grodner, M., Roth, S. L., Walkingshaw, B. C., & Grodner, M. (2012). Nutritional

foundations and clinical applications: A nursing approach (6th ed.). St. Louis, MO:

Mosby/Elsevier.