It is not "just old age"
You see it before the scales do: trousers turning round, rings slipping off, a face that has hollowed. Then you are told "at that age they eat less".
As an explanation that is wrong. Unintentional weight loss in a care home is a quality indicator, not a biological inevitability — and it nearly always has a findable cause. The mistake is not worrying; it is accepting the first answer.
The thresholds that oblige action
Write them down and quote them: losing 5% of body weight in a month, or 10% in six months, is malnutrition to be investigated, not a fluctuation. Homes should be screening with a tool such as MUST and acting on the score. At those numbers, a nutritional assessment and a written plan are not a favour.
The causes to rule out, in order
- The mouth. The commonest and most overlooked: broken teeth, oral thrush (white coating, burning), dentures gone loose after weight loss — so they hurt — so she eats less — so she loses more. Ask for a dental and oral check.
- Swallowing. Coughing at meals, a wet voice, meals that take forever, repeated chest infections: signs of dysphagia. Ask for a speech and language therapy referral — modified textures change everything, and an aspiration avoided is a hospital admission avoided.
- Medication. Many drugs blunt appetite, dry the mouth or cause nausea. Ask for a medication review: in an older person, stopping a drug is sometimes the best treatment.
- Pain and constipation. Nobody eats with a blocked bowel or a pressure sore that stings. These are the silent causes in someone who no longer explains.
- Depression. Common after moving in, often mistaken for dementia, and it takes appetite before anything else.
- The dementia itself: forgetting how cutlery works, not recognising food, being too distracted to finish. That is not refusal.
The cause nobody admits: no one helps her
Here is what families discover by turning up at a mealtime unannounced: the tray is put down and taken away almost untouched. Someone who can no longer lift a fork to her mouth does not need a special menu — she needs a person sitting beside her for twenty minutes. In a short-staffed home, that is the first thing to disappear.
Come at lunchtime without warning and watch: how many staff for how many residents in the dining room, who is assisting, how long the meal lasts, whether the television is blaring. You will know in ten minutes.
What you can insist on, in writing
- regular weighing — monthly at least, weekly while she is losing — and sight of the weight chart;
- food and fluid charts over several days (what is actually eaten, not what is served);
- referral to a dietitian and, where swallowing is affected, to speech and language therapy;
- a medication review by the GP;
- mealtime assistance written into the care plan, with the time it takes;
- food fortification (cream, butter, cheese, protein powder in what she already eats) rather than only supplement drinks that sit there.
What actually works
Smaller portions more often; finger food for someone who can no longer manage cutlery; the dishes of her own life rather than the standard menu; eating in company rather than alone in her room; the time of day when appetite is best (often breakfast); and calm — a noisy dining room reduces how much people eat.
The feeding tube question in advanced dementia
If tube feeding is raised in advanced dementia, know that the evidence does not show longer survival or fewer aspiration pneumonias. The recommended approach is comfort feeding: offering food by hand, at her pace, for pleasure and comfort. You can ask for a palliative care opinion before any decision — and you can decline. If she has an advance decision or a lasting power of attorney for health and welfare, this is where it matters.
If the home cannot provide mealtime help
Help with eating is not a comfort extra; it is basic care. If a home cannot provide it, your relative is not "difficult" — the home is mismatched to her level of need.
Curalune Care Help (£69) puts together, usually within 24 working hours, a shortlist of 3 to 5 homes that fit — with the questions to ask about mealtime assistance, dining-room staffing and modified textures.
*General information, not medical advice. Rapid weight loss or a fever should be assessed without waiting.*
