Malnutrition & the older patient

1. Malnutrition & the older patient James T. Birch, Jr., MD, MSPH Assistant Clinical Professor – Dept. of Family Medicine Division of Geriatric Medicine Landon Center on Aging KU Medical Center February 19, 2007

2. Objectives • Outline the ACOVE indicators for malnutrition for community-dwelling and hospitalized older persons • Understand the physiologic changes that contribute to the problem • Identify the risks of malnutrition in the elderly patient • Discuss nutritional screening and assessment tools

3. Objectives • Review basic nutritional requirements for the older patient • Discuss options for nutritional intervention • Review the ethical considerations for replacement of nutrition and hydration of the older patient • Identify nutritional syndromes

4. Definition • Malnutrition is the condition that develops when the body does not get the right amount of vitamins, minerals, and other nutrients it needs to maintain healthy tissues and organ function. The condition may result from an inadequate or unbalanced diet, digestive difficulties, absorption problems, or other medical conditions. However, there is no universally accepted clinical definition.

5. “Malnutrition is not something observed only in third-world countries.”1 “Older persons suffer a burden of malnutrition that spans the spectrum from under- to overnutrition.”2 “Malnutrition in the elderly is one of the greatest threats to health, well-being, and autonomy….” 1. Kiseljak-Vassiliades, K., et al. Basic Nutrition for Successful Aging: Part 1. Clinical Geriatrics, Vol. 14(4); April 2006 2. Geriatrics Review Syllabus: A Core Curriculum in Geriatric Medicine, Sixth Edition (GRS6); American Geriatrics Society 2006 3. Francesco, VD, et al. The Anorexia of Aging. Digestive Diseases 25(2); 2007

6. ACOVE - 3Quality indicators for Malnutrition ACOVE-3 indicators are comprised of IF-THEN-BECAUSE statements Apply to community-dwelling AND hospitalized older persons 8 quality indicators covering 4 domains Indicators are not supported by RCTs (except one) because most all studies have been small and involved persons who met “narrow” entry criteria or which lacked the highest quality of methodological rigor. Indicators are a product of literature review and expert panel consideration.

7. ACOVE-3 quality indicators Indicator #1:ALL community-dwelling pts. Should be weighed at each physician office visit and these weights should be documented in the medical record BECAUSE this is an inexpensive method to screen for energy undernutrition and obesity that has prognostic importance.

8. ACOVE-3 quality indicators Indicator #2: IF a vulnerable elder has involuntary wt. loss of > 10% of body wt. over one year or less, THEN wt. loss (or a related disorder) should be documented in the medical record as an indication that the physician recognized malnutrition as a potential problem BECAUSE some patients with wt. loss have potentially reversible disorders.

9. ACOVE-3 quality indicators Indicator #3: IF a community-dwelling vulnerable elder has documented involuntary wt. loss or hypoalbuminemia (< 3.5g/dL), THEN she or he should receive an evaluation for potentially reversible causes of poor nutritional intake BECAUSE there are many treatable contributors to malnutrition.

10. ACOVE-3 quality indicators Indicator #4: IF a community-dwelling vulnerable elder has documented involuntary wt. loss or hypoalbuminemia (< 3.5g/dL), THEN he or she should receive an evaluation for potentially relevant comorbid conditions including: Medications that might be associated with decreased appetite (digoxin, fluoxetine, anticholinergics), depressive symptoms, and cognitive impairment BECAUSE each of these represents a treatable contributor to malnutrition.

11. ACOVE-3 quality indicators Indicator #5:IF a vulnerable elder is hospitalized, THEN his or her nutritional status should be documented during the hospitalization by evaluation of oral intake or serum biochemical testing (e.g., albumin, prealbumin, or cholesterol) BECAUSE each of these measures has prognostic significance and can identify older persons at risk of malnutrition or adverse outcomes (complications, prolonged length of stay, in-hospital and up to one-year mortality).

12. ACOVE-3 quality indicators Indicator #6: IF a hospitalized vulnerable elder is unable to take foods orally for more than 72 hours, THEN alternative alimentation (either enteral or parenteral) should be offered BECAUSE such patients are at high risk of malnutrition that can improve with caloric supplementation

13. ACOVE-3 quality indicators Indicator #7: IF a vulnerable elder who was hospitalized for a hip fracture has evidence of nutritional deficiency (thin body habitus or low serum albumin or prealbumin), THEN oral or enteral nutritional protein-energy supplementation should be initiated post-operatively BECAUSE RCTs have indicated better outcomes in these pts.

14. ACOVE-3 quality indicators Indicator #8: IF a vulnerable elder with a stroke has persistent dysphagia at 14 days, THEN a gastrostomy or jejunostomy tube should be considered for enteral feeding BECAUSE this method of feeding has improved outcomes compared to oral feeding.

15. Contributors to risk of malnutrition • The elderly are at higher risk of developing protein-calorie malnutrition and other vitamin and mineral deficiencies. • The frequency of these events increases with advancing age due to problems such as poor dentition, loss of taste, difficulty swallowing, malabsorption, and drug-nutrient interaction

16. Contributors to risk of malnutrition • Other physical limitations such as inability to obtain necessary food due to lack of transportation and dependence on others for shopping, lack of financial resources, and functional limitations can contribute to nutritional deficiencies

17. Contributors to risk of malnutrition • Non-perishable foods frequently contain high amounts of sodium and nitrates, and processing can remove vitamins. • Many drugs cause anorexia, gustatory changes, and anosmia as major side effects. • Medications can also interfere with nutrient availability

18. Risk Factors for Poor Nutrition Status

19. Physiology-the “anorexia of aging”

20. Physiology-the “anorexia of aging”

21. Physiology • Changes in physiology, metabolism, body composition, and physical function in the older patient may alter nutritional requirements, so that standards applicable to younger patient or middle-aged adults cannot be applied to the elderly

22. Physiology • Changes in body composition • Decreased bone mass • Decreased lean mass • Decreased water content • Increased total body fat (greater intra-abdominal fat stores) • Decline in organ function is highly variable among individuals and may affect assessment and intervention options

23. Physiology • Serum albumin is a recognized risk indicator for morbidity and mortality but is not an indicator of malnutrition because it lacks sensitivity and specificity. • A modest decline does occur with aging • Half-life is ~ 20 days • Sensitive to hydration state and presence of inflammation, surgery, and other severe disease

24. Physiology • Hypoalbuminemia in the A. Community Setting Functional limitation Sarcopenia Increased health care use Mortality

25. Physiology • Hypoalbuminemia in the B. Hospital setting Increased length of stay Complications Readmissions Mortality

26. Physiology • There are some reports which express the use of caution with using albumin as a measurement of nutritional status in “hospitalized” patients. It is inversely correlated with markers of inflammatory activity (ESR, CRP) and can behave as an acute-phase reactant, with markedly reduced levels in the setting of acute illness.

27. Physiology • Prealbumin half-life ~ 48 hours • Responds rather quickly to increased protein intake • Controversial with regards to its use as a marker of malnutrition • Best used in conjunction with other parameters (i.e. exam, BMI, CRP, hx of wt. loss, and various nutritional assessments) • Also affected by changes in transcapillary escape due to infection, inflammation, etc.

28. Physiology • Cholesterol Serum cholesterol has been linked to nutritional status. Levels <160mg/dl have been detected in patients with malignancy or other severe disease states. Community-dwelling elderly with both hypoalbuminemia and hypocholesterolemia exhibit higher rates of functional decline and mortality than those with either one alone.

29. digoxin phenytoin SSRI’s / lithium Ca++ channel blockers H2 receptor antagonists / PPIs Any chemotherapy metronidazole narcotic analgesics K+ supplements furosemide ipratropium bromide theophylline spironolactone levodopa fluoxetine Drugs that can cause ANOREXIA

30. Drugs can interfere with senses of taste and smell • More than 250 medications reportedly disturb gustatory sensation • More than 40 drugs reportedly disturb the sense of olfaction • A few of these agents have been objectively determined to affect these functions via experiments, clinical trials, or intensity scaling

31. Gustation Allopurinol Amitriptyline Ampicillin Baclofen Dexamethasone Diltiazem Enalapril Hydrochlorothiazide Imipramine Labetalol Mexiletine Ofloxacin Nifedipine Phenytoin Promethazine Propranolol Sulfamethoxazole Tetracyclines Olfaction Amitriptyline Codeine Dexamethasone Enalapril Flunisolide Flurbiprofen Hydromorphone Levamisole Morphine Pentamidine Propafenone Drugs That Interfere With Gustation (taste) and Olfaction (smell)

32. Drug-nutrient interactions • Many of the aforementioned drugs and others interfere with the absorption of various vitamins and minerals • Examples: Antacids- Vitamin B12, folate, iron, total kcal Diuretics- Zn, Mg, Vitamin B6, K+, Cu Laxatives- Ca, Vitamins A, B2, B12, D, E, K

33. Drug-Nutrient Interaction

34. Basic Nutritional Requirements for the Older Patient • Estimated total daily energy need (based on body weight): 25-30 kcal/kg/day • Estimated total daily energy need (based on basal energy expenditure; BEE): Harris-Benedict Equation Male BEE = 66 + (13.7 x kg) + (5 x cm) – (6.8 x age) Female BEE = 655.1 + (9.563 x kg) + (1.850 x cm) - (4.676 x age) Results should be multiplied by 1.5 to estimate energy expenditure of ill elderly patients

35. Basic Nutritional Requirements for the Older Patient • Carbohydrates should comprise 45-65% of total calories • Fat should comprise 20-35% of total calories • Protein should comprise 10-35% of total calories • Fluid : 30ml/kg/day or 1ml per kcal intake

36. Basic Nutritional Requirements for the Older Patient • Estimation of protein: (0.8 to 1.5)gm/kg/day Restriction of these amounts may be indicated in renal or hepatic insufficiency • Estimation of fiber: (complex carbohydrates are the preferred fiber source) Men: 30 gm/day Women: 21 gm/day (see the 1-30-30 rule on the pocket card)

37. Nutritional Screening and Assessment • Nutrition Screening Initiative (NSI): collaborative effort of AAFP, ADA, and the National Council on Aging • NSI completed a study in 1996, revealing evidence that older patients admitted to the hospital in poor nutritional states had longer stays and increased rates of complications than well-nourished patients.* * Bagley, B; Nutrition and Health (Editorial); AFP, 57(5): March 1, 1998

38. Nutritional Screening and Assessment • The NSI developed a screening tool that can be completed by patients, family members, or a health care professional • The tool consists of 10 questions which are scored and placed in 3 categories: No nutritional risk 0-2 points Moderate nutritional risk 3-5 points High nutritional risk >6 points

39. Nutritional Screening and Assessment • NSI (points apply to “YES” answers) • I have an illness or condition that made me change the kind and/or amount of food I eat (2) • I eat fewer than two meals per day (3) • I eat few fruits or vegetables, or mild products (2) • I have 3 or more drinks of beer, liquor, or wine almost every day (2) • I have tooth or mouth problems that make it hard for me to eat-2 • I don’t always have enough money to buy the food I need (4) • I eat alone most of the time (1) • I take 3 or more different prescribed or OTC drugs per day (1) • Without wanting to, I have lost or gained 10 or more pounds in the last six months (2) • I am not always physically able to shop, cook and/or feed myself (2)

40. Nutritional Screening and Assessment • Mini Nutritional Assessment (MNA) is a validated screening and assessment tool for identifying elderly patients with or at risk for malnutrition • Developed by the Nestlé Research Center, in collaboration with hospital clinicians

41. Nutritional Screening and Assessment • The MNA obviates the need for blood tests to screen and monitor a patient’s nutritional status • Composed of two sections: Screening and Assessment

42. Nutritional Screening and Assessment • MNA Screening: In the screening section, five questions are asked, and the patient's BMI (Body Mass Index) is calculated, using the patient's height and weight. From these six items, a score is calculated, which will indicate whether there is possible malnutrition • Screening score: (max. 14 pts) > 12 pts Normal; not at risk < 11 pts Poss. malnutrition; go to assessment

43. Nutritional Screening and Assessment • MNA Assessment: Clarifies whether there is a future risk of malnutrition, or if malnourishment is currently present. The assessment section is comprised of 10 questions, and two anthropometric measures – mid-arm circumference and calf circumference. • Scoring (max. 16 pts); when added to screening score, total max is 30 pts. If total is 17-23.5 pts, pt is at risk of malnutrition and if <17 pts, the pt is malnourished.

44. Nutritional Screening and Assessment • The MNA has demonstrated acceptable internal consistency, inter-observer reliability, and validity in studies of community-dwelling, hospitalized, and nursing home elderly individuals around the world and in the U.S. Beck, A., et al. European Journal of Clinical Nutrition. Nov 2001, Vol 55(11); 1028-33

45. Nutritional Screening and Assessment • Limitations of use of MNA: Lack of familiarity with the requirement of measuring both mid-arm and calf circumference

46. Nutritional Screening and Assessment • Geriatric Nutritional Risk Index (GNRI): requires measurements of height, albumin, and weight at admission (also ideal weight as calculated from the Lorentz equation). Nutritional risk is graded based on results of calculations. It is a more reliable prognostic indicator of morbidity and mortality in hospitalized elderly. Low albumin and elevated CRP correlate statistically with increased nutritional risk (stronger than with prealbumin)

47. Body Size Classification

48. Nutritional Syndromes • Undernutrition-3rdleading condition in hospital and home care sites and 4th leading condition in office practice and nursing homes for which QI efforts would improve the functional health of older persons.

49. Nutritional Syndromes • Undernutrition: it is often clinically difficult to physically distinguish “cachexia” from “wasting” Cachexia – (REE is increased) Wasting – (REE is decreased) *REE – Resting energy expenditure

50. Nutritional Syndromes • Obesity – prevalence extends to the 60-70 age group • Adverse outcomes associated with obesity include impaired functional status (esp. BMI>35), increased health care resource use and increased mortality • Poor diet quality and micronutrient deficiencies are common in obese elderly pts., especially women who live alone