Florence Gill, 93 and suffering from dementia, needed a little help each day dressing, bathing and eating. She was, by all accounts, doing well -- until she entered a nursing home to recover from an eye infection.
In just four weeks, the 5-foot-1 former schoolteacher dwindled from 88 pounds to 72 pounds.
Her son Gerald visited twice a week but didn't notice the weight loss because his mother was always covered by a blanket. Nurses assured him that she was eating.
By the time his mother was free of the infection, it was too late. Dehydrated, underweight and covered in bedsores aggravated by poor nutrition, she died in a hospice facility early last year -- three days after leaving the nursing home.
"I try to watch things," said Gerald Gill, a 63-year-old engineer who checked the home's ratings on an Internet site and toured the facility before sending his mother there. "I was impressed." He was encouraged that families of other residents seemed satisfied with the care.
Gerald Gill will never know exactly why his mother's health deteriorated so rapidly, although it is clear that a lack of life-sustaining food and drink played a major role. Although Florence Gill's situation may have been exacerbated by a nursing home staff that didn't act aggressively enough or alert her family to her physical decline, thousands of other elderly patients in the nation's 17,000 nursing homes are also wasting away from too little food or water.
Although nursing homes are required to keep records of how much residents eat and drink and to track their weight, it's difficult for researchers to determine how often inadequate food and fluids play a role in their deaths. Death certificates rarely mention dehydration or excessive weight loss.
It is roughly estimated that 35 percent to 85 percent of the nation's 1.7 million nursing home residents are at risk of malnutrition and dehydration. The range is broad because there have been no large national studies and there is no consensus on what health measures should be used. No matter the measure, the problem exists even at some of the costliest facilities.
Simply providing three square meals a day to an elderly resident doesn't mean the meals are eaten. That's because the reasons someone won't eat can be complex. The aging process itself can dull one's sense of taste or hunger, and illness and disability often are factors. Other reasons may include a dislike of institutional food or understaffed nursing homes that can't provide enough individual attention for residents.
Even seniors who still live at home can be undernourished, but the risks increase in hospitals, where busy staffs may provide only limited attention. Some studies estimate that 20 percent of hospital patients receive less than half their needed nutrition.
The situation is most severe in nursing homes, where residents are dependent for most daily needs on low-wage, overworked nurses and nursing assistants.
While nursing assistants typically feed from five to 20 people in about an hour, University of California, Los Angeles, researchers found that it takes an average of 40 minutes for one nursing home resident to finish a meal.
UCLA aging researchers have found in several related studies that about seven out of 10 nursing home residents fail to finish 75 percent of their food -- the federal government's yardstick for measuring the risk of malnutrition.
The findings suggest that inadequate staffing or poor quality care are not the only explanations for why some elderly patients won't eat, said Jack Schnelle, director of UCLA's Borun Center for Gerontological Research. Even when the staff uses charm or persuasion to get older patients to eat, sometimes people "just don't want the food."
Researchers at the Borun Center are studying how different approaches, such as more frequent but smaller meals and an improved variety of food, affect the eating habits of nursing home residents.
But "nothing is simple" with these patients, Schnelle said.
For more information on malnutrition and dehydration in the elderly, contact the advocacy group the National Citizens Coalition for Nursing Home Reform. The group provides information on nursing-home quality issues, including nutrition and hydration. Call 202-332-2275 or visit www. nccnhr.org.