I'm very fustrated. Having come out of a Complex Care unit I've seen conditions deteriorate, but this is also heartbreaking in a different sort of way.

Try THC, a.k.a. "medical marjuana" or "pot". It is a great appetite and mood enhancer. It doesn't have to be smoked, it can be ingested in various forms, or inhaled as a vapour.

I've given it in pill form Arminius, not for appetite so much at the time. Interesting.

I would say it is a social problem. Are they being visited by family and friends. have they lost their spouses, and are in need in grief work. Do they get the help they need to overcome the barriers that they face in life. if not, i do not see how pills, will help.

Of course it's a social problem.

In the village culture I grew up in, old people stayed with their extended families unless and until they required a level of care that the family was unable to provide.

In almost every other house there was a whizened old man or woman, sitting by the stove, being part of the family, even if they could no longer see or hear or chew their food very well or hold their bladder. Just being there and being connected to their family made them feel good.

I now live in a "retirement town." 30% of the people are seniors, many of them housed in seniors housing complexes or care homes. My wife worked in homecare, and now volunteers for seniors care. The biggest problem among the seniors is loneliness.

To be alone without feeling lonely is a difficult art that one has to train for for a lifetime. When one is very old, it is often too late.

Also many people derive their purpose in on doing as opposed to being. I make the money, or I cook etc. Once illness or disability takes ability, we need to either remove the barriers to doing, or to learn to be loved just for being. The eledly are no different than younger peopel who also because of disability or illness start to feel hopelessness.

It is a challenge especially for men, to cook for one person after their wife dies. It also is a challenge to eat by yourself if you live alone.
I have experienced a natural way and a bad way of not eating.
Dont forget, that not eating is a natural part of dying.i remember patients with chronic/ palliative conditions who just stopped eating and died peacefully. It took a while.
I also remember patients who could not swallow safely anymore who s life was prolonged unnecessary by family who force fed them because they couldn t let go. Or doctors who keep running IVs, prolonging the dying process.

Some people are at peace with not eating and dying, others who say they want to die and don t eat are rather depressed and negative. Then, the depression has to be dealt with. It depends on what state the person is in.

Interesting post Waterfall - as March is Nutrition Month in Canada.  Today I went to a lecture about the role of nutrition in prevention & managment of pressure ulcers which was very interesting.

Malnution (and dehydration) is a HUGE problem - and being elderly is a significant risk factor.   Even those who eat, often eat poorly in terms of nutritional value.   Maxing out protein is really important, and often institutional food is light on protein, sadly. 

I agree with mrsanteater - not eating can be a symptom of depression.  Proper assessment for depression can be helpful - if indicated, antidepressant meds can certainly increase appetite (in fact some are particularly noted for it). 

Poor dentition can also be a factor - if there has been weight loss, dentures may not fit properly, making eating uncomfortable or painful.  Sometimes relining them can improve the situation - or substituting soft or minced diet.  Or sometimes there is an unattended cavity causing sensitivity, irritation, or sweet sensitivity (ouch to Ensure!) that comes with receeding gums - using different toothpaste can help.  

Sometimes the tastebuds are kinda 'worn out' and less sensitive - so food taste bland and uninteresting - so upping the seasoning can be useful - but in institutional food the opposite is usually the case! 

Ensure/Boost etc. often can also be had in pudding form - more palatable to some.  Some of my folks say having the liquid over ice helps the taste.  

And finally, yes - sometimes people have just had enough of living & wish for their life to finish up.  That's not necessarily depression or suicidal ideation, more like fatigue of waiting.  I encounter it fairly often in my work.  Distinguishing this from depression can sometimes be tricky, and the approach & support is different.

I admire your interest and committment to your residents.  I sense you will make a difference in their lives, whether or not they get back to eating.  

So how do people determine if someone is suffering from "fatique of waiting" or depression, or loneliness, or grief/loss that can be addressed.  

Alex I'd be interested in hearing an answer for that myself.

Carolla, thankyou so much for some excellent points. Sometimes working in one area of nursing one forgets to ask and seek out some issues staring us right in the face. For instance, yes the one man has terrible teeth. another has lost so much wieght, I'll bet his dentures are loose. One person is Italian and would like more spicy and more "homecooked" meals, and I like the idea of Ensure or Boost in pudding form.....I am definitely going to seek out some of that!

mrs.anteater, I have noticed that when a spouse dies, often it's not long for the other half to die also, especially if they're much older.

Today, one was sent to hospital. He'd lost so much weight.

It really makes one wonder why we set these facilities up in such an elegant fashion and yet we fail to recognize that even in old age we seem to still need a purpose to exist.

great thread, waterfall.  I have learned items.

I think a lot of our elderly were brought up on wholesome, nutriional, "real" food.  And most probably carried on in their own homes eating way even after "processed packaged" food hit the supermarkets and our world.  And in their "golden" years find themselves in care homes where the food, in some cases, is nothing like what they have eaten most of their lives.

A lot of reason have been presented in this thread as to why the elderly might not want to eat, and for each one their own personal reasons are probably made up of a combination of the reasons stated here, and possibly more.

For some, could it be possible that medications they are taking make a difference in their appetite?

I think a lot of our elderly were brought up on wholesome, nutriional, "real" food.  And most probably carried on in their own homes eating way even after "processed packaged" food hit the supermarkets and our world.  And in their "golden" years find themselves in care homes where the food, in some cases, is nothing like what they have eaten most of their lives.

A lot of reason have been presented in this thread as to why the elderly might not want to eat, and for each one their own personal reasons are probably made up of a combination of the reasons stated here, and possibly more.

For some, could it be possible that medications they are taking make a difference in their appetite?

A situation I recently encountered - an elderly woman living in a large retirement home; her physical status had deteriorated & her activity tolerance and energy level had nosedived because of this.  She was always proud of her appearance, and found herself without sufficient energy to 'put myself together decently' - i.e. dressing & grooming; and so she didn't like to go out of her unit.  She also had a long walk to the dining room - too long now, so that also was a reason to stay in.   Once identified, additional supports were put in place to assist her with self care activities and to transport her to the dining room.  Yes - meal trays could be delivered - as the RH stated; but eating is a social activity, not merely about having food in front of oneself.  So there was advocacy needed to help them understand this (sadly!).  

Here's an interesting link - http://www.drheatherkeller.com/   Dr. Keller is doing some great work on seniors & nutrition.    

Waterfall - do you know if nutritional risk screening is done when people move into your facility?  It's been initiated at the hospital (although it's tough to get staff to do it routinely). 

Hi Alex - it's generally done on the basis of skilled clinical interview, review of medical history & ruling out of modifiable medical factors,  and collection of collateral information - for example finding out details about when the situation started or changed & correlated that to other life events.

It's usually done by someone with expertise in geriatric care - often a mental health specialist.   It's a complex "bio-psycho-social" look at the whole person, to try to tease out what is contributory - sometimes all are part of the picture, as you might imagine. 

a talk by a researcher who has been studying Lonliness

note: it is quite lethal & is part of our many systems telling us when something is wrong

here's a more academic, detailed talk, with references & more symptomology

I sometimes look on the WonderCafe as a place where I can say something that I would have to be very careful saying anywhere else.

I'm wondering if some old people have simply decided to stop living.  Their lives have stopped being meaningful and enjoyable.  They feel they are an increasing burden on others.  Their money is gone.  They have nothing to look forward to.   Perhaps their bodies are frail.  They are losing control of their body functions.  They know that they are slipping mentally - that before long they will lose not just their short term memory, but theeir ability to think, reason, read, follow a TV program, converse, or even know those dearest to them.  They remember saying many times  "I don't want to be like that."   or  "Please take me Lord before I reach that stage."

And they lose interest in food.  They don't want to eat.  They just want it to be over. 

And maybe we should leave that choice up to them.

great lecture inanna - thanks. (edit - I watched the first video - while I was posting I see you added another - I will check that out later)

true seeler - these are the sentiments of many folk.  Sometimes we (generally reference to society & families at large) are not so good at responding with respect and support in such situations.  As we respect this position, do you have thoughts about how to support? 

What an incredible, useful thread about a difficult topic.  I have learned a lot from it, though I have no experience with dealing with elderly folk who aren't eating.

It must be very challenging to find out 'why' and then to know what  is, and isn't, ethical to do about it.  From the safety of 'never had to deal with it' I can easily say 'If someone is tired of living and stops eating as a form of suicide we should allow that' - but how heart wrenching if it is your parent!

I once had a distant elderly in-law who (I thought) was chronically depressed, under nourished (she ate but not much nutritious food), spent hours at a time just sitting (usually with her KJV on her lap), shared the same basic thoughts at every visit - 'It is too hard and sad to get old - all my friends have died - no one knows who I was when I was young - all I can do is wait to go to Jesus'

 She lived in a small suite in a Seniors Housing project and wasn't interested in participating in any of the activities that went on. She didn't listen to the radio or watch the TV or read, or do handwork of any type.  My partner once said "I can't beleive that she doesn't die of utter boredom". The rest of the family didn't visit any more frequently than my partner and I (once every year or two) and her situation remained fairly static for 20 years!

I am aware of someone wanting to die, actually 2 people, who wanted to die and had quit eating and it was through tough love and treating underlying ailment that they got their zest for life back

I'm wondering how one would tell, for themselves or for a loved one, when it is right to let the body slow down and shut off, and when with tough love, or whatever, it is right to urge them to fight on in hope for improved quality of life.    Maybe there won't be any 'quality of life' but just prolonged suffering.

We keep pushing death away.  But all that lives must die eventually.  At one time pneunomia was called 'the old man's friend', something that would set in when he was bedridden and breathing shallowly, and he would die.  Now it's treated with antibiotics and his body kept alive for months, years - perhaps curled in a fetal position, maybe in pain, the mind long gone.  No dignity.  No hope for improvement.   I want to go before it comes to that.   So when I take a single sip of water, then clamp my lips shut, and turn my head away - please don't try to force me to take 'just one bit' and then 'that wasn't so bad.  Now, just one more.'    And no feeding tubes; or introvenous feedings. 

In both cases, these individuals were capable of good quality of life, seeler, for a significant length of time.

I understand your point and would not iv feed someone who was no longer there

Your comments seeler, and pinga, are so important.  It emphasizes the need - while one is healthy - to have discussions with family members about future wishes, so they can be guided should they ever be in a position to have to make such decisions. 

In terms of discerning whether or not to push - having good medical understanding of the current situation & likely prognosis can be very helpful in deciding which road to take. 

Interestingly - this morning on CBC radio I heard Michael Enright interview John Cacioppo - the person featured in the videos Inanna posted upthread.   I'm reminded of the statement "coincidence is just God's way of remaining anonymous." :-)   There was some good discussion on distinguishing loneliness from depression. 

The interview is (or soon will be) likely available in the CBC radio archives - I haven't looked but invite others to do so & post a link if found. 

Can you give me more details Pinga?

No they haven't started any nutritional risk screening at the facility. Can you tell me more about it? It appears that those that are becoming malnourished, seem to have walked in healthy, which makes me wonder if the "change" in coming to a facility also promotes not eating. Of course they are there for a reason in the first place, so I would guess some of those risk factors would take into account if it was their choice or their childrens. You wouldn't believe in the few months I've been there how many come for a "visit"  under the premise that this is just something that is temporary and then of course it develops into a permanent situation. (which seems to have been the plan all along) I think more honesty may be in order too.

Now this brings to mind what one of the younger nurses stated when one gentleman was sent to the hospital for "failing to thrive". She was embarassed, in a way, because she was worried that the hospital staff would interpret his not eating as a fault of the caregivers at the facility, which of course wouldn't be true. There are many concerned. The diagnosis that was phoned back to us was "malnoutrition". I think it felt as if it was sort of "yucky" that we have some malnourished people and we're supposed to be taking care of them.

How can a nurse say, "don't push the food or encourage it" if it's very clear that that person doesn't want to eat and would prefer to die? This is a dilemma for me. Backing off when they're still walking around or in a wheelchair, still able to feed themselves and hold a conversation? And then there's the one that can't communicate so well but you sense that they are purposely forgoing food.

The one I can give without issue, it was my mother.

She had terrible pain in her jaw from trigemnial neuralgia. It had been going on for a while.  She had quit eating withut my knowledge. she was wanting to die.  There is a reason this pain is called the suicide disease.  I found out as we had to go to emergency as she had not gone to the washroom for 3 weeks (bowel impaction) and she articulated her desire at that time.  I was blunt, said all that was going to get her was more and more hospital visits, etc..and that we needed to address the core issue.  We went to the doctor's together, we worked through various meds and she got her life back. 

The other was someone who did not want to go to emergency room , articulated they just wanted to die.  When the core issue was addressed, they thanked the individuals who had got them there.

Re nutrition screening & info - Dr. Keller, as noted above, has developed SCREEN - which might be helpful.   There are also good resources at the Canadian Malnutrition Task Force website - http://nutritioncareincanada.ca/    The stats are rather shocking in terms of the extent of malnutrition.  

It might be really interesting to review the menu choices at your facility - presently, hospital menus (mine included) are noted to be somewhat abysmal in terms of nutritional value related specifically to healing - so quite possibly that may apply also to your setting.  Is there a dietician on staff (she asked hopefully, but not optimistically)  Sometimes getting a student to take on your facility as a refiew & recommendation project is an option.  

I have also been aware of an elderly person hearing "you should eat less read meat" and cutting red meat totally out of their diet.  In the case that I was involved in, I ended up having to reintroduce spices and a few meats to a diet that had been made very bland and boring due to taking a little comment from a doctor way out of perspective to what was intended.

the difference between the one that doesn't eat out of depression and the one that doesn't eat because it's their time to go can be experienced in their attitude. I had patients who consciously decided against eating or feeding tubes knowing that they will die.
In the normal dying process there is a time when people stop eating. People around them will see how much at peace they are.
The one person I know right now who doesn't eat and wants to die is overall negative and very needy- calling the nurses for a lot of things.
The one person I saw before was at peace with her decision and it was clearly her way out. She lived about four or five weeks. She might have eaten or tasted something sometimes when she wanted to. She had a lot of visitors coming and going and eating was just not an issue. Everyone accepted her decision.

Yes, I think it is a viable option. I really liked some of the posts on this thread regarding the importance of analysing.  Interesting skill set and complexities.  I honour those of you who walk this journey with folks regularly. ...I am sure LB also encounters it.

I haven't read all the posts so my apologies if I repeat or ignore something.

One thing I am going to say is this, retirement homes are not long term care homes.  The residents of a retirement home retain the right to refuse cae.  This makes it harder in these situations.

I am going to continue on the assumption that all medical reasons have been ruled out.  The individuals have been thoroughly checked for tumours that could be make eating uncomfortable.  They are not suffering from any physical disabilities that make chewing difficult and have been assessed for food allergies and intolerances.

If they are wearing dentures have these been checked to see if they still fit?  Gums shrink with age and ill fitting dentures can make eating difficult and in some cases painful.  Also are they clean, again food trapped under the plate can make eating uncomfortable.

Has the Food Service Manager talked to the resident?  Food preferences change over time.  Certain health conditions, like strokes, can change how some foods taste - more salty for example.  Any one who suffers from acid reflux or a hiatus hernia will begin to reject food because of the pain.  These resident may need to eat smaller meals spread out through the day.  Find out what the resident likes and encourage them to enjoy those foods, that may get them back on track.

Beware of sundowning, the effect of dementia increasing as the day wears on.  A dark dining room can depress the apetite and lead to outbursts.  Also these residents should be encouraged to eat throughout the day and not discouraged when they forget they have eaten and ask for more.

Aging is a grief process.  The older we get the more we lose and depression is a reasonable response to the mutiplying grief.  I have found that the best cure for that is one on one attention.  Make the person feel special.  

We have one gentleman who used to spend most of his day in his room and would often not come to meals.  As hard as I tried to get him to participate in activities he refused, except for Bingo he loves Bingo.  Then we were lucky to get a volunteer to act as a receptionist and I noticed he was sitting there talking to her.  I would make a fuss over him whenever I went by getting him a coffee and a snack.  He has blossomed.

Staff also need to take care in how they deal with depressed residents.  The gentleman above is a gruff old bear and a big tease.  When he first arrived staff thought he was rude and treated him coldly.  Me, being me, assumed he was teasing and treated it as such.  Again, he blossomed and once the staff got on board he is still a gruff old bear but with a twinkle in his eye.

Depressed residents need that little extra love.  They respond to touch and smiles.  A cup of tea and a cookie stop tears and outbursts.  I know how crunched we all are for time in our jobs but taking those few minutes to offer up that human kindness can save an hour coping with a behavioural outburst.

If behaviour modification fails then it is time to call in the big guns.  I am not sure where you are Waterfall but if there are geriatric mental health services available call them in.  They will develop the one on one programmes needed to deal with the grief.

This is a very long response but this is an issue very close to my heart.  Too often I see the grief of the elderly dismissed and ignored.  The young tend to think, like all the indignities of aging, their elders should just suck up the sadness and put up with it.  A little understanding and a lot of love can make all the difference.

LB

----

“She had to live in this bright, red gabled house with the nurse until it was time for her to die... I thought how little we know about the feelings of old people. Children we understand, their fears and hopes and make-believe.” 

― Daphne du Maurier, Rebecca

Great comments LB - your residents are SO fortunate to have you on board!    "A little understanding and a lot of love can make all the difference."   Amen!

We've lost so much of this in some facilities & hospitals - makes me feel sad. 

Hi LB, nice to hear from you again and some very wise and amazing advice, thankyou. It's always good to be reminded what love can do in our lives.

I am currently checking into some resources available for mental health. I also asked those who work in the kitchen what specific nutrition training they had and unfortunately it doesn't seem they hold any formal training. Even a diabetic diet isn't offered. Those in charge seem open for more training if offered though. That is somethng I will have to take up with management....Comes down to dollars unfortunatley, I would advise anyone placing their parents anywhere to ask about some of these issues and be specific.

Great effort on your part waterfall!  Wow - not even diabetic diet?  That is very surprising.  It may be well worth their money to hire a consultant dietician (with specialization in geriatric nutrition) to review and revise the menus periodically.  

We had a great speaker from Abbott Canada (company that makes Ensure) who did the presentation last week re pressure ulcers & would healing.  It really stuck in my mind that she said for healing, 75gm/day of protein is required - usually delivered in divided amounts over the 3 meals & snacks/day - as that's quite a lot of protein.  But what do we give people for breakfast?  Muffin, toast, maybe cereal, and maybe a tiny bit of cheese - no more eggs!  Carbs are cheap, protein often more expensive.  But even if residents had the information, they might add supplements themselves in terms of good snack choices etc. 

Money - yes - always important - I think that's why our hospital food has changed so much - nutrition maybe is seen as an 'efficiency' area, not an essential to health that can influence length of stay & patient experience too. 

A good thread is getting increasingly better!

I read about the kitchen staff with no nutrition training, Waterfall,  and shook my head in amazement.  It should be automatic that diabetic needs are met!  

If I was involved in the situation I think I would look to the nutritionists hired by the local health providers - the people who provide the hospitals etc.  In my area they have trained people who could maybe be asked to provide training to the kitchen staff,  Possibly they could also provide meal plans that could be selected from depending on what items are in season, and therefore a better buy.

This type of thing happens way too frequently, I think.  

agreed

Diabetics don't really need special diets. They just need info on the carbohydrate content of what is served. And healthy food choices. 

We match the carbohydrate content to our insulin or oral medication. 

p3 - good point.  What happen though as someone develops cognitive impairment, as can be the case when needing to move to a care facility or assisted living?   I did a brief stint with a complex diabetes care team a few years ago, and was amazed by the rather high level of cognitive demand to self-manage diabetes - wondered if I'd even be up to it myself! 

Obviously, I'm not an expert in diabetes - just aware of some of the complexity of living with it as I hear others talk. As people age and need more help with the activities of life, it seemed to me to indicate that some might need more help handling the demands of their diabetes. 

sorry - double post.  This site DOES like to make people repeat themselves!

Diabetic meal plans don't require any special food to be prepared, that's all I am saying Carolla.

You are right about the cognitive demands to manage the disease. It goes well beyond monitoring one's food intake. 

sidetopic, but, one of the items that I discussed with my gun-carrying coworkers who are all getting carry permits and carrying guns is the impact of an aging population.  Just think, not only do you need to negotiate diabetes and eating right, or macular degeneration and driving, you get to negotiate taking guns away too!

Tangent Alert. 

Curious about gun-carrying coworkers, Pinga!

I am located in Canada but 98% of the people that I intereact with are not Canadians, they could be anywhere in the world.  (Tongith, I am work for some interactions with overseas folks).

Of the non-Canadians, many are in Wisconsin or Ohio.

Of the Wisconsin folks, many now have carry permits.  They have target shooting nights.  They invited me and I have a standing invite to go again.  I am anti-guns for anything than hunting for food; however, it was a good opportunity to spend time with bright articulate folks many of which are as liberal as me, though might better be described as libertarian, as to why they belive and advocate for carry permits.

Got it now, Pinga. 

Very informative thread.

Taking guns away......!!!!...well...bless my whiskers...I never thought about that one! There is something new under the sun after all.

agreed