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Nutrition and Malnutrition in the Elderly

Nutrition and Malnutrition in the Elderly. Goals, Objectives, Standards. Goals Appreciate the scope of nutritional assessment and intervention in the medical care of the elderly Objectives Practice use of nutrition screens Practice implementation of nutritional interventions

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Nutrition and Malnutrition in the Elderly

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  1. Nutrition and Malnutrition in the Elderly

  2. Goals, Objectives, Standards • Goals • Appreciate the scope of nutritional assessment and intervention in the medical care of the elderly • Objectives • Practice use of nutrition screens • Practice implementation of nutritional interventions • Code correctly for evaluation and treatment • Standards • Use DETERMINE nutritional screen • Use Mini Nutritional Assessment • Compute Body Mass Index • Compute Ideal Body Weight • Compute Energy Needs • Compute Protein Needs

  3. Case Phase 1: Evaluation of Outpatient • 82 yr female on a fixed income lives at home alone and is dependant upon friends as for transportation. She has HTN, CAD, CRF, and OA all modestly controlled on HCTZ, ACE1, TNG, beta-blocker, and acetaminophen. Her chief complaint is having trouble dressing herself secondary to L shoulder pain. You note a 10 pound weight loss since her last visit six months ago. • What do you do next?

  4. Demographics • Malnutrition • Independent 0-6% • Skilled Care 2-27% • Hospital 10-30%, up to 75% • Stay is longer with more malnutrition

  5. MACRONUTRIENTS I • Water • 8 x 8 oz/d • 30ml/kg/d or 1ml/kcal eaten • Carbohydrates 55-60% total kcal/d • ½ carbs from whole grains • Proteins 1 to 1.5 gm/kg/d • Fats <30% total kcal/d • Cholesterol < 300 mg/d • Fiber > 4 gm/d

  6. Macronutrients II • Electrolytes • Na <2300 mg/d (1 tsp), <1500 mg/d blacks • K K rich foods , >4700 mg/d blacks • Mg • Calcium 1200 mg/d • Phosphorous 700 mg/d • Iron 25-40 mg/d

  7. Vitamins, Co-factors Minerals Trace Elements Multivitamin Multivitamin Multivitamin Micronutrients

  8. Anthropometrics I • Clinical • 10 pound loss in six months or weight < 100 lbs • Relative Risk of Death 2.0 • PPV of malnutrition = 0.99 • Minimum Data Set • Weight loss >= 5% past month • Weight loss >= 10% past six months

  9. Anthropometrics II • BMI : Body mass index = weight (kg) / height (m2) • Correlated to nutrition status, morbidity, mortality • 18.4 and lower greater risk malnutrition and related diseases • 30 and higher the greater risk for DM, CAD, HTN, OA, CA • National Practice Standard = Compute @ each office visit • Underweight <18.5 • Normal weight 18.5-24.9 • Overweight 25-29.9 • Obesity >= 30 • Extreme Obesity >= 40

  10. BMI Table http://www.nhlbi.nih.gov/guidelines/obesity/bmi_tbl2.htm

  11. BMI: NIH Recommendations • Clinicians should measure BMI and offer obese patients intensive counseling and behavioral interventions. • The National Institutes of Health provides a BMI calculator at www.nhlbisupport.com/bmi and a table at www.nhlbi.nih.gov/guidelines/obesity/bmi_tbl.htm. • The Centers for Disease Control and Prevention provides a BMI calculator at www.cdc.gov/nccdphp/dnpa/bmi/calc-bmi.htm.

  12. Anthropometrics III : Research tools • Skin fold and mid-arm circumference • Water Displacement • Bioelectrical Impedance • Dual Radiographic Absorptiometry • CT • MRI • Total Body 40K

  13. Wasting - Severe weight loss and diminished nutritional intake Semistarvation Reduced metabolic demand Visceral protein sparing Obvious weight loss RA, CHF, COPD, HIV, Critical care without nutritional support Cachexia - Inflammatory cytokine mediated wasting Semistarvation overlap Increased metabolic demand Visceral protein wasting ECF incr masks weight loss Limited response to antiinflammatory/anabolics Nutritional intervention slows semistarvation part Marasmus, CA, HIV with opp inf, critical care without nutritional support, chronic organ failure Wasting and Cachexia

  14. Protein-Energy Undernutriton • Clinical wasting + albumin < 3.5 gm/dl • > 1/3 hospital • < 1/3 NH • < 10% independent • Big cachexia overlap • Nutrition support • Treat underlying disease

  15. Failure to Thrive • Not a defined syndrome in the elderly

  16. DETERMINE Screening Tool • D isease • E ating poorly • T ooth loss, mouth pain • E conomic hardship • R educed social contacts • M ultiple medications • I nvoluntary weight loss or gain • N eed for assistance in self-care • E lderly (age > 80)

  17. DETERMINE Evaluation • Read the statements below. Circle the number in “YES” column for those that apply to you or someone under your care. For each “YES” answer, score the number n the box. Total your nutrition score. • I have an illness or condition that made me change the kind and/or amount of food I eat 2 • I eat fewer than 2 meals a day 3 • I eat few fruits or vegetables, or milk 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 three or more different prescribed or over-the-counter drugs a day 1 • Without wanting to, I have lost or gained 10 pounds in the last 6 months 2 • I am not always physically able to shop, cook, and /or feed myself 2 • Note: Scoring: 0-2 = good, 3-5 = moderate nutritional risk, 6 or more = high nutritional risk DETERMINE Your Nutritional Health Checklist. Nutrtion Screeining Initiative, a project of the American Academy of Family Physicians, the American Dietetic Association, and the National Council on Aging, Inc., and funded in part by Ross Products Division,

  18. Mini-Nutritional Assessment (MNA) • Two Part • 3 min screen • 8 min diagnostic • Validated against measurable standards • Inclusive, Plenary

  19. MNA Part 1 Skill Session

  20. MNA Part 2 Skill Session

  21. MNA Study Results • Oral supplementation in skilled living elderly with MNA 17-23.5 and < 17 with 1 can (400 kcal) significantly increased: • calorie intake • MNA score about 3 points • Weight about 1.5 kg • Alzheimer’s • Supplementation at 2 kg weight loss stabilizes weight loss compared to controls

  22. Food Pyramids • MyPyramid.gov • Culturally distinct • More flexible

  23. MyPyramid.gov • Grains – gold • Vegetables – green • Fruits – red • Oils – yellow • Milk – Blue • Meats + Beans – Purple • Discretionary Calories • < 200 to 300 kcal • Exercise • 30, 60, 90 rule

  24. Age Specific Recommendations • People over age 50. • Consume vitamin B12 in its crystalline form (i.e., fortified foods or supplements). • Older adults, people with dark skin, and people exposed to insufficient ultraviolet band radiation (i.e., sunlight). • Consume extra vitamin D from vitamin D-fortified foods and/or supplement

  25. Numerous Ca, Mg, Fe Phytins (in fiber) Tannins (coffee, tea) Bind drugs/nutrients Bind drugs/nutrients Bind drugs/nutrients Nutrient-Nutrient/Drug Interactions

  26. Alcohol Antacids Antibiotics Colchicine Digoxin Diuretics Isoniazid Levodopa Laxatives Zn, A, B1, B2, B6, B12, folate B12, folate, Fe, kcal K B12 Zn, kcal Zn, Mg, B6, K, Cu B6, niacin B6 Ca, A, B2, B12, D, E, K Drug-Nutrient Interactions I

  27. Lipid Binding Resins Metformin Mineral Oil Phenytoin Salicylates SSRI Theophylline Trimethoprim A, D, E, K B12, kcal A, D, E, K D, folate C, folate Kcal Kcal folate Drug-Nutrient Interaction II

  28. Nutrient Treatment of Disease • Ca and Vit D for osteoporosis • B6, B12 for homocysteinosis • Antioxidants CAD, Macular Degeneration • Vitamin E failed for AD • Watch for overdosing of vitamins!

  29. Case Phase 2 – Outpatient Treatment • She responds to in-home physical therapy after a steroid injection of her L shoulder. She starts to eat breakfast and uses a supplement when her appetite is poor. Meals on wheels brings her one meal a day. She eats with a friend who cooks every Tuesday at lunch. She gains back 7 pounds.

  30. Case Phase 2 : Hospital Evaluation • Your patient falls and breaks her left hip. She survives a L total hip replacement, but develops pyelonephritis with bacteremia at the hospital. She is delirious. She loses 15 pounds. • What do you do now?

  31. Nutrition Requirement Calculations 1 • Estimated Energy Needs by Weight • 25-30 kcal / kg body weight / day • Use 120% IBW for obese persons • Estimated Protein Needs by Weight • Protein = (0.8-1.5) gm / kg body weight / day • Use IBW for obese persons • May need to be higher (2.0-3.0) for stressed and or very malnourished persons.

  32. Nutrition Requirement Calculations 2 • Harris-Benedict Basal Estimated Basal Energy Expenditure (BEE) • Male BEE = 66 +(13.7 x weight in kg) + (5 x height in cm) – (4.7 x age) • Female BEE = 665 +(9.6 x weight in kg) + (1.8 x height in cm) – (4.7 x age) • Multiply by 1.00 (non-stressed) to 1.50 (stressed)

  33. Laboratory Evaluation • Albumin < 3.8 g/dl • Lacks sensitivity and specificity • May decline very slightly with age • Negative acute phase reactant • Prealbumin • Shorter half-life than albumin • No more predictive • Cholesterol < 160 mg/ml • Indicates underlying serious disease in community, hospital and NH patients • Total Lymphocyte Count < 2000 cells/microliter

  34. Tube Feeding • 3-7 days of 1-2 kcal/ml supplement • Convert to PEGE for “long term” use • 1500-2400 ml per day to achieve water, protein, calorie goals • Start full strength, increase rate • Measure residuals, convert to bolus feeds • Supplement enzymes • Treat diarrhea • Deal with aspiration

  35. TPN • For non-functioning GI tract • No EMB studies in elders

  36. Case Phase 2: Hospital Treatment • After pulling out her NG tube every shift for 24 hours, she is given TPN through her central line. After 48 hours, she is dyspneic, hypoxic, and edematous. • What do you do now?

  37. Re-feeding Syndrome • Syndrome of • hypophosphatemia • hypomagnesemia • fluid retention • about 3 days into re-feeding • Most pronounced with parenteral nutrition • Occurs with oral re-feeding as well • More severe with worse malnutrition • Frequent subclinical presentation • Reduce re-feeding rate for three days to treat

  38. Case Phase 3: Skilled Facility Evaluation • She recovers from bacteremia, and since she cannot tolerate a rehab schedule due to residual delirium and weakness is placed in skilled care. While there, she does poorly in PT/OT. Has restricted diet order for CHF. On narcotics, anxiolytics. She is depressed, constipated, requires 1-2 person assists for ADL’s. She has no appetite.

  39. Drugs Anemia Uremia Liver Disease Dry Mouth Pain Cancer Inflammation Psychiatric Illness Bowel Disease Constipation Malnutrition Anorexia

  40. Anorexia : Appetite Stimulation • Food Appearance • Salt • Sugar • Social Contact • Feeding • Ambience • Familiarity • Drugs • Ghrelin, other hormones

  41. Anorexia : Pharmacologic Support • Mirtazipine • probably works • Cannabis, Cannabinoids, Tetrahydrocannabinol and its derivatives • No therapeutic effect or use in medicine • Ritalin • Unsure, probably in depression • Estrogens/Progestins/Thalidomide • Probably risk of DVT is too high for routine use • Corticosteroids • Especially in cancer, hematologic, neurologic • Prokinetics • Cyproheptadine • Hydrazine sulphate – no utility • Dronabinol • Antiserotonergic drugs • Branched-chain amino acids, Eicosapentanoic acid • Melatonin

  42. Sarcopenia of the Elderly • Age related loss of skeletal mass • Type I fibers spared • Type II loss of number and size • Questions: • Sedentary • Dietary • Hormonal • Neurologic • Sex hormonal

  43. Case Phase 4 • Recovers

  44. ICD-9 Codes • Malnutrition • 1st degree (mild) 263.1 • 2nd degree (moderate) 263.0 • 3rd degree (severe) (protein calorie) 262 • From neglect 995.84 • Causes problems for NH • Hypoalbuminemia / Hypoproteinemia 273.8 • Protein Deficiency / Kwashiorkor 260 • Marasmus 261 • Causes problems for NH • Senile Marsmus 797 • Intestinal Marasmus 569.89 • Lack of Food 994.2 • Nutritional Deficiency, particular, specify 269.9 • Undernourishment/Undernutrition 269.9 • Weight loss (cause unknown) 783.21 • Failure to thrive 783.7 • Causes problems for NH

  45. Treatment of Malnutrition • Ease dietary restrictions • Supplements • Foods • Enhanced Milk or Soy based products • Drugs • Supportive Therapies

  46. Summary • Malnutrition is prevalent in the elderly • Reproducible assessment is available • Intervention prevents morbidity and mortality • Supplements have a role in therapy

  47. Cobbs EL, Dithie EH, Murphy JB, eds. Geriatrics Review Syllabus: A Core Curriculum in Geriatrics Medicine. 5th ed. Malden, MA: Blackwell Publishing for the American Geriatrics Society; 2002. MyPyramid.gov United States Department of Agriculture Screening for Obesity in Adults. What's New from the USPSTF? AHRQ Publication No. 04-IP002, December 2003. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/clinic/3rduspstf/obesity/obeswh.htm http://www.mna-elderly.com/ Cornali, Cristina, Franzoni, Simone, Frisoni, Giovanni B. & Trabucchi, Marco (2005)ANOREXIA AS AN INDEPENDENT PREDICTOR OF MORTALITY.Journal of the American Geriatrics Society53 (2), 354-355.doi: 10.1111/j.1532-5415.2005.53126_4.x Visvanathan, Renuka, Macintosh, Caroline, Callary, Mandy, Penhall, Robert, Horowitz, Michael & Chapman, Ian (2003)The Nutritional Status of 250 Older Australian Recipients of Domiciliary Care Services and Its Association with Outcomes at 12 Months.Journal of the American Geriatrics Society51 (7), 1007-1011.doi: 10.1046/j.1365-2389.2003.51317.x http://www.nhlbi.nih.gov/guidelines/obesity/bmi_tbl2.htm Bibliography Journal of the American Geriatrics SocietyVolume 52 Issue 10 Page 1702  - October 2004doi:10.1111/j.1532-5415.2004.52464.x Persson, Margareta D., Brismar, Kerstin E., Katzarski, Krassimir S., Nordenström, Jörgen & Cederholm, Tommy E. (2002) Nutritional Status Using Mini Nutritional Assessment and Subjective Global Assessment Predict Mortality in Geriatric Patients. Journal of the American Geriatrics Society50 (12), 1996-2002.doi: 10.1046/j.1532-5415.2002.50611.x

  48. Bibliography • Hematol Oncol Clin North Am. 2002 Jun;16(3):589-617.Related Articles, Links • Update on anorexia and cachexia.Strasser F, Bruera ED.Department of Palliative Care and Rehabilitation Medicine, MD Anderson Cancer Center, 1515 Holcombe Boulevard, Box 0008, Houston, TX 77030, USA • Anorexia and cachexia in advanced cancer patients.Vigano A, Watanabe S, Bruera E.Palliative Care Program, Edmonton General Hospital, Canada. • Cancer anorexia-cachexia syndrome: current issues in research and management.Inui A. http://www.bccancer.bc.ca/PPI/UnconventionalTherapies/HydrazineSulfateHydrazineSulphate.htm

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