Counseling Session: Older Adult with Unintentional Weight Loss. David Hoang and John Rhee. Dr. Gretchen George
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1 Counseling Session: Older Adult with Unintentional Weight Loss David Hoang and John Rhee Dr. Gretchen George DFM Nutrition Education and Communication November 1,
2 1 Introduction The unintentional weight loss associated with older adults over the age of sixty can lead to more serious conditions. Increase risk of infection, disease state, and even death can occur when significant body weight and muscle mass are lost in elderly patients. There are a variety of factors that can cause involuntary weight loss such as depression, cancer, cardiac disorder, and gastrointestinal disease. Weight management is aimed to find and treat the underlying causes and increase nutrition support. Considering the patient s age, nutritional intervention can be difficult, so appropriate approach method needs to be utilized in the counseling session. Counseling the client should target increasing patient s awareness of the inherent risks and negative conditions associated with their weight loss, and provide support and self-efficacy for the client to reach his goal. Background The client is Chonghie Han who is a 74 year old male experiencing unintentional weight loss. As a retired pastor, he spends most of his time writing books, sitting down for most of the day. He enjoys daily walks lasting around 30 minutes. Chonghie s wife, Jaeim, is concerned about his weight loss and advised him to seek nutrition counseling. Mr. Han is five feet and seven inches tall. His usual body weight for most of his adult life was 142 pounds. He currently weighs 128 pounds. He lost 14 pounds in the span of 4 months, which equates to roughly a 10% reduction in usual body weight. His teeth were replaced with dentures 6 months ago due to poor oral health. He reports having a loss in appetite and not eating as much as he used to. He claims the food he eats does not taste or smell the same and he is not enjoying his meals. Also, Mr. Han have difficulty chewing his food which further adds to the problem.
3 2 As the human body age, there may be many factors that contribute to unintentional weight loss. It is common for older adults to experience a loss of skeletal muscle and consequently, body weight. Involuntary weight loss can be categorized in three main etiologies of sarcopenia, starvation, and cachexia. Sarcopenia is characterized in the reduction of strength and muscle mass associated with normal aging. As individuals get older, motor unit number and atrophy of muscle fibers decrease (Thomas, 2007). Starvation occurs with inadequate protein and energy intake, which results in the loss of body fat and muscle mass. Cachexia is a wasting syndrome in relation to severe chronic illnesses such as cancer or immunodeficiency disease (Thomas, 2007). It is important to distinguish these different changes in body composition in order to effectively respond with clinical nutrition intervention. Mr. Han is not suffering from any chronic illnesses or disease, and his general health is relatively in good terms. Knowing this, cachexia can be ruled out as a potential factor in Mr. Han s involuntary weight loss. To a lesser degree, sarcopenia may be a contributing factor due to Mr. Han s age. The cause of sarcopenia can be correlated with hormonal changes, but no clear causation of sarcopenia have been defined (Thomas, 2007). Mr. Han s weight can be a combination of starvation and sarcopenia, or just starvation alone. Without proper body composition measurements using dual-emission X-ray spectrometry, or bioelectrical impedance, it would be difficult to eliminate sarcopenia as a factor for Mr. Han s reduction in weight. For this reason, nutrition management should emphasize adequate protein intake. The patient should also be recommended to see a medical doctor concerning sarcopenia. Starvation is very evident in Mr. Han s case as he reports eating only one or two meals a day. Unintentional weight loss in the elderly population can arise from physical, psychological, and social conditions as well as age-associated changes. According to research, as much as 25%
4 3 of elderly patients have no identifiable cause for their weight loss (Alibhai, Greenwood & Payette, 2005). When an apparent weight loss occurs in elderly patient without evidence of a disorder or disease, primary malnutrition should be considered as the main contributor (Alibhai, Greenwood, & Payette, 2005). The significant change in body weight occurred after Mr. Han s teeth were replaced with dentures, further suggesting the cause of starvation, thus leading to weight loss. In research, Hildebrandt, Dominguez, Schork, & Loesche (1997) claims that the reduction in the number and quality of functioning teeth can have deleterious effects on the overall health of the individual and more so for individuals over the age of 55 years. People with dentures or compromise masticatory functions have reported avoiding foods that they considered too difficult to chew and tend to shift towards soft and easy to chew foods. This avoidance practice often result in low fiber and protein diets that may decrease total caloric intake for the person. Certain disease states, debilitation, and short life expectancy in elderly people is a common outcome due to poor nutritional status. Increased mortality and morbidity are associated with unintentional weight loss of 4-5% or more within a year, or 10% or more over the course of 5-10 years (Alibhai, Greenwood, & Payette, 2005). Treatment of involuntary weight loss often requires promoting access to good nutrition, and enhancing food intake. Risk factors such as poor dental health, chewing or swallowing difficulties, stress, and poverty should be targeted. It is crucial that dietitian and social workers are involved in the assessment and The use of oral nutritional supplements can help reverse weight loss, but not always. Rather than consuming supplements with meals, patients should be advised to consume their supplements in between meals instead. This can help mitigate appetite suppression and increase
5 4 total calorie intake. It is also important to note that elderly people are at risk of vitamins and mineral deficiency due to inadequate food intake, thus a wide range of vitamins and mineral supplements should be added as part of their nutrition management (Splett, Roth-Yousey, & Vogelzang, 2003). Counseling Approach Health belief model is the best concept to understand Mr. Han s case. According to the Health Belief Model, cognitive factors influence an individual s decision to make and maintain a specific health behavior change (Bauer, 2012, p.18). In Mr. Han s questionnaire, he indicated that he would like to improve his eating habits and learn to manage his weight; he also stated that he wants some structure and freedom to select his foods. From these statements, it is clear that Mr. Han perceives the weight loss as a problem, but he does not have the knowledge or tools to find a resolution. His desire to gain weight is also an indicator that he sees the benefits in gaining weight. Following the health belief model, it would be ideal to help him plan for what actions he must take in order to reach his goal. The self-efficacy in this case would be critical, as the confidence in being able to work around his barriers to implement the intervention would be key in changes of dietary habits. As Mr. Han is an older adult over the age of 60, appropriate interviewing strategies were essential. In Basic Nutrition Counseling Skill Development, 2nd ed., Bauer, Liou & Sokolik (2012) writes that the interviewing strategies for adults include using sensitive language, motivational interviewing, bias free care, and setting specific, measurable, realistic goals (p.237). In order to approach the client, motivational interviewing was incorporated in the counseling. Motivational interviewing is defined by the founders Miller and Rollnick as, a client-centered, directive method for enhancing intrinsic motivation change by exploring and
6 5 resolving ambivalence (Bauer, Liou & Sokolik, 2012, p.30). By this approach, the interview will be client-centered, where counselor will be listening reflectively, which would reduce resistance and enable the client to explore the problems, barriers, and options. Since Mr. Han is aware of his weight loss problem and the barriers in maintaining weight, some structure and advice to edify the knowledge of how he can gain weight would be beneficial. Prior to interview, the client s basic health information and questionnaire was assessed. It is essential that the counselor eliminates any judgments or prejudices and carefully evaluate the client s health status and knowledge without creating resistance. The counselor should state the objectives of the counseling session, and outline the goals for the patient at the beginning of the interview. Counseling Application In the interview session, motivational interviewing was incorporated. During the interview, the counselor continued to paraphrase and ask questions in reflection to the client s responses. This was to emphasize on reflective listening, expressing to the client that the counselor is actively listening. The feedback for the patients included formal information that laid out facts for the client to refer to, leading to questions that allowed the client to explore the options of intervention. By allowing the client to identify problems and discover the possible causes and the resolution, the content of the interview was led by the client; that is clientcentered, while the counselor led the direction of the interview with appropriate questions. Open-ended questions were often asked so that the client would not feel led by the counselor, which can create resistance in the process of the interview. The times that close-ended questions were asked, the counselor explained the intentions of his questions. Throughout the counseling session, the counselor was respectful of the client, and non-judgmental. In response to the
7 6 client s answers, the counselor continued to paraphrase and give neutral feedback. Incorporating small talks in the conversation showed support and help establish close rapport with the client. In the closing phase of the interview, the counselor summarized the session, restated the goals, and asked a question reflecting self-efficacy. This allowed the counselor to evaluate whether the client has comprehended the necessary steps to reach his goal. Conclusion Changing behaviors of older adults can be complex, as there are multiple factors that influence their decisions. For an older adult who is aiming to gain weight while struggling with physiological barriers due to aging and other factors, a competent counseling method is essential for changing health-related behaviors. No one counseling method is ideal; however, practical and successful counseling sessions are ones that are tailored to specific clients or patients. It was important that Chonghie Han s health condition and knowledge was assessed prior to the counseling session, and the appropriate method of approach was planned. Identifying the level of the client s understanding of weight loss and his barriers was important for the counselor to direct the client to explore from his own standpoint. With the incorporation of motivational interviewing, the counselor provided support and efficacy for the client. With an appropriate approach to counseling, the client will be more susceptible to change and motivated in reaching the overall goal. Communication is only as effective as the method in which it is delivered..
8 7 References Alibhai, S. M., Greenwood, C., & Payette, H. (2005). An approach to the management of unintentional weight loss in elderly people. Canadian Medical Association Journal, 172(6), Bauer, K. D., Liou, D., Sokolik, C. A. (2012) Basic Nutrition Counseling Skill Development, 2nd ed. Belmont:Wadsworth, Cengage Learning Hildebrandt, G. H., Dominguez, B. L., Schork, M. A., & Loesche, W. J. (1997). Functional units, chewing, swallowing, and food avoidance among the elderly. The Journal of prosthetic dentistry, 77(6), Splett, P. L., Roth-Yousey, L. L., & Vogelzang, J. L. (2003). Medical nutrition therapy for the prevention and treatment of unintentional weight loss in residential healthcare facilities. Journal of the American Dietetic Association, 103(3), Thomas, D. R. (2007). Loss of skeletal muscle mass in aging: examining the relationship of starvation, sarcopenia and cachexia. Clinical Nutrition, 26(4),
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