Geriatric Nutrition http://www.aecom.yu.edu/nutrition/presentation/Presentation.htm

1. Geriatric Nutritionhttp://www.aecom.yu.edu/nutrition/presentation/Presentation.htm Nutrition Theme Course Academic Year 2008 CJ Segal-Isaacson EdD, RD Alice Fornari, EdD, RD Judy Wylie-Rosett, EdD, RD

2. Session Objectives • To help students find practical ways of integrating nutrition assessment and treatment into geriatric medicine. • To learn more about nutrition therapy for unintentional weight loss, malnutrition, hypertension, stroke and dysphagia. • To identify geriatric nutrition resources on the web.

3. AECOM Nutrition Website: http://www.aecom.yu.edu/nutrition/default.htm • Particularly useful parts of the AECOM Nutrition website: • Nutrition resources: http://www.aecom.yu.edu/nutrition/links.htm • Nutrition presentations: http://www.aecom.yu.edu/nutrition/presentation/Presentation.htm • Nutrition Handbook for Medical Professionals http://www.aecom.yu.edu/nutrition/NutritionHandbook.htm

4. “I’m just not Hungry” Geriatric Nutrition Case #1 Lauren Cantor, MBA; Alice Fornari, EdD; CJ Segal-Isaacson, EdD; Darwin Deen, MD and Lisa Hark, PhD Chief Complaint: Mrs. Heraldo is a 78 year old Latina woman brought in by her niece to you, her new primary care provider. The niece is concerned that Mrs. H looks much thinner. Mrs. H seems unconcerned about her weight loss and just repeats she is old now and “just not hungry.” Mrs. H has no idea if she has lost weight. However, her chart documents that she is 5’4” tall and weighed 174 lbs (BMI 29.9 kg/m2) 3 months ago. Today she weighs 154 lbs (BMI 26.4 kg/m2).

5. Continuation of Chief Complaint: The niece explains that her aunt lives alone in a subsidized, senior housing facility. Mrs. Heraldo tells you that her two children, both grown, live in California and Arizona and she sees them about once a year. Her husband died 5 years ago. Her eyes tear a bit as she tells you this.

6. Discussion Question #1-4 • What is the percentage of body weight that Mrs. H has lost in the last three months? • Given that Mrs. H’s BMI is still in the overweight range, is her weight loss currently a significant issue? Why or why not? • What should our weight goals for Mrs. H be at this point? • Is Mrs. H’s weight loss to be expected at her age? Why or why not?

7. Involuntary Weight Loss in the Elderly • Total body weight tends to peak in the 50s, remains stable until 70 and then slowly declines after age 70-75. • Loss of lean body mass (LBM) starts in the 20s typically with a 0.3 kg loss each year and which is usually offset by an increase in body fat that continues at least until 65-70 years of age. • This can represent a loss of 40% of LBM! • Weight loss per se is NOT a normal part of aging. In the very healthy elderly, weight loss is typically in the range of only 0.1 to 0.2 kg per year.

8. Two studies found that intentional weight loss also led to increased mortality due to loss of LBM, bone, and malnutrition from overly restrictive diets. • Epidemiology • The incidence of involuntary weight loss in community-dwelling elderly is between 5-15% of that population and more than 25% in frail elderly receiving home care services. • One year documented weight loss of greater than 4-5% was the single best predictor of death within two years. (Wallace et al.). • Newman AB, Yanez D, Harris T, Duxbury A, Enright PL, Fried LP. Weight change in old age and its association with mortality. J Am Geriatr Soc. Oct 2001;49(10):1309-1318. • Wallace JI, Schwartz RS, LaCroix AZ, Uhlmann RF, Pearlman RA. Involuntary weight loss in older outpatients: incidence and clinical significance. J Am Geriatr Soc. Apr 1995;43(4):329-337.

9. Discussion Question #5 • How do the physical effects of weight loss from decreased energy intake (reduced calories) differ from cachexia? What are the physiological effects of both?

10. Body Composition Changes • Simple weight loss (From decreased caloric intake) • 70-80% body fat • 20-30% lean body mass • Cachexia: (From chronic inflammation) • 70-80% lean body mass • 20-30% body fat • Cachexia-related metabolic changes: • Hepatic acute-phase protein synthesis • Increased skeletal muscle breakdown • Negative nitrogen balance • Increased lypolysis • Hyperinsulinemia • Increased gluconeogenesis • Wallace JI, Schwartz RS. Epidemiology of weight loss in humans with special reference to wasting in the elderly. International Journal of Cardiology. 2002/9 2002;85(1):15-21.

11. Discussion Question #6 • What are some of the causes of inadequate food intake in the elderly?

12. The Nine “Ds” of Inadequate Food Intake and Weight Loss In The Elderly: • In about 25% of cases, there is no clear etiology for weight loss. • When etiology is established the most frequent reasons are: • Depression • GI (peptic ulcer or motility disorders) • Cancer

13. Discsussion Questions #7-8 • What questions would you ask Ms.Heraldo to help narrow down the possible causes of her weight loss? • What other tests would you consider performing?

14. Diagnostic Algorithm • Wallace JI, Schwartz RS. Epidemiology of weight loss in humans with special reference to wasting in the elderly. International Journal of Cardiology. 2002/9 2002;85(1):15-21.

15. Discussion Question #9 • To recoup: How much weight loss is considered a clinically “significant” amount to lose over a 12 month period?

16. Past Medical and Surgical History • Mrs. H has hypertension and hyperlipidemia, which were diagnosed 15 years ago. She has been on various hypertensive medications over the years. Her current regimen consists of Hydrochlorothiazide 25 mg daily, Atenolol 50 mg daily, Norvasc 5 mg daily, and Zocor 40 mg daily. • Her family medical history includes hypertension and diabetes in both parents and an older sister who died from a stroke 5 years ago at the age of 76. Mrs. H denies any other significant past medical history. • When asked about her weight history, she recalls that she “was an average girl” until after her first child at which point she gained about 15 lbs with each of her three children. She also says that she gained about 20 lbs when she stopped smoking 20 years ago.

17. Discussion Question #10 Match the side effects associated with the medications Mrs. H is taking. • Zocor a. depression • Norvasc b. hepatitis • Atenolol c. peripheral edema

18. 1 with b 2 with c 3 with a

19. Discussion Question #11 Which of the following medications may cause loss of appetite in the elderly? • NSAIDS • Psuedoephedrine • Theophylline • Megestrol Acetate • Antineoplastics • Antihistamines

20. Appetite loss: • Psuedoephedrine, Theophylline, Antineoplastics. • Increased appetite: • NSAIDS, “Megace” and Antihistamines.

21. Discussion Question #12 • Is there an appetite stimulant we should consider prescribing to Mrs. H? If so, what are they?

22. Appetite Stimulants: • Megestrol Acetate (Hydroxyprogesterone) • Promotes appetite and causes weight gain but most studies show increased weight is fat, not LBM • Side effects may include fluid retention, nausea, glucose intolerance, venous thrombosis, reduced testosterone levels • Marinol/Dronabinol • Recent retrospective study1 shows that it was well-tolerated in the elderly and showed modest weight gains of 3  8.01lbs. Major side effect is dizziness. Frequently given at night before bed to mitigate dizziness. 1. Wilson MM, Philpot C, Morley JE. Anorexia of aging in long term care: is dronabinol an effective appetite stimulant?--a pilot study. J Nutr Health Aging. Mar-Apr 2007;11(2):195-198.

23. Growth Hormone • A 4 week trial showed slightly faster weight gain than no medication but no long-term sustained effect over food alone.1 Growth hormone in other settings have shown increased mortality. Also, growth hormone must be given by injection. • Oxandrolone and Nandrolone • Several small trials in the elderly with androgenic analogs have not shown they lead to enhanced weight gain. • Testosterone (In men with low levels) • May be useful for elderly men with hypogonadism to build muscle back. 1. Chu LW, Lam KS, Tam SC, et al. A randomized controlled trial of low-dose recombinant human growth hormone in the treatment of malnourished elderly medical patients. J Clin Endocrinol Metab. May 2001;86(5):1913-1920.

24. Cyproheptadine • This is an antihistamine that increases appetite through its antiserotonergic effect on 5-HT2 receptors in the brain. However, a trial done in 1990 did not show that cyproheptadine was effective in promoting weight gain in cachexic cancer patients. • Non-Pharmacological Appetite Stimulants • Alcohol and Salty Nibbles • Although this is anecdotal information, a little wine or beer and a few salty mouthfuls such as olives eaten before a meal may enhance appetite. • Encourage greatest food consumption when patient is most rested. 1. Kardinal CG, Loprinzi CL, Schaid DJ, et al. A controlled trial of cyproheptadine in cancer patients with anorexia and/or cachexia. Cancer. Jun 15 1990;65(12):2657-2662.

25. Brief 24 Hour Food Recall • Mrs. H lives alone and reports that she shops and cooks for herself. She says that she eats two meals a day and that she eats pretty much the same thing every day. Her 24 food recall for yesterday is: • Morning: 1 cup of instant coffee with non-dairy creamer, 1 tsp sugar and 1 slice toast with 1 tsp margarine and 1 tsp jam. • Noon: 1/2 can chicken noodle soup, 3-4 saltines and 1 slice American cheese. • Evening: 1 broiled chicken thigh, 1 spoonful of string beans and 1 spoonful rice. • She drinks at least 5 cups of water a day and sometimes has a cup of tea with 1 teaspoon sugar and 2-3 vanilla wafer cookies before bed. • She takes a daily multivitamin/mineral supplement.

26. Discussion Question #13 • Approximately how many calories is Mrs. H eating each day? • Breakfast? • Lunch? • Dinner? • Evening Snack?

27. Total: On a good day, maybe 1000 calories! • Breakfast: ~200 calories • Lunch: ~200-300 calories • Dinner: ~200-300 calories • Evening Snack: ~ 200 calories

28. Discussion Question #14 What formula could we use to quickly estimate Mrs. H’s total daily caloric requirements?

29. Although Mrs. H weighs 154 lbs (70 kg) her energy needs should be calculated based on her ideal weight of 125 lbs or 56.8 kg as fat tissue is less metabolically active than muscle. • In general, energy requirements for weight maintenance can be estimated for older adults using the formula of 30 kcal/kg of ideal body weight. For Mrs. H this translates to about 1700 kcal per day. • As we age our level of physical activity is usually reduced resulting in lean body mass being replaced by fat and a lowering of metabolic rate. • There is a normal reduction in appetite in the elderly but sometimes it surpasses the reduced metabolic rate and physiologic anorexia results. • The National Research Council estimates energy requirements for adults to be: (see chart, next slide)

30. Calculating Energy Requirements

31. Discussion Question #15 What formula should we use to calculate Mrs. H’s ideal protein intake?

32. Recommended protein intake for adults, including the elderly is 0.8 g/kg of ideal body weight. • Although the RDA for protein for adults is set at 0.8 g/kg ideal body weight, a study by Campbell et al.1 found that 0.8 g/kg was inadequate to maintain nitrogen balance. They found that 1-1.25 g/kg of ideal body weight was necessary. • Mrs. H’s recommended amount of protein would be approximately 70g of protein per day. This would translate into 10 ounces of high protein food per day. Campbell, W. W., Crim, M. C., Dallal, G. E., Young, V. R., & Evans, W. J. (1994). Increased protein requirements in elderly people: new data and retrospective reassessments. Am J Clin Nutr, 60(4), 501-509.

33. Discussion Question #16 • What are some other instruments for assessing diet and physical activity?

34. Nutrition Screening Tools • Nutrition Screening Initiative • Developed by the American Academy of Family Physicians at: http://www.aafp.org/online/en/home.html • Mini Nutritional Assessment: MNA® • Developed by Nēstles

35. Determine Your Health Nutrition Screening Tool • I have an illness or condition that made me change the kind and/or amount of food I eat. Yes (2 pts.) • I eat fewer than 2 meals per day. Yes (3 pts.) • I eat few fruits or vegetables, or milk products. Yes (2 pts.) • I have 3 or more drinks of beer, liquor or wine almost every day. Yes (2 pts.) • I have tooth or mouth problems that make it hard for me to eat. Yes (2 pts.) • I don't always have enough money to buy the food I need. Yes (4 pts.) • I eat alone most of the time. Yes (1 pts.) • I take 3 or more different prescribed or over-the-counter drugs a day. Yes (1 pts.) • Without wanting to, I have lost or gained 10 pounds in the last 6 months. Yes (2 pts.) • I am not always physically able to shop, cook and/or feed myself. Yes (2 pts.)

36. How To Score Nutrition Screening Tool • 1-2 points Low Risk • 3-5 points Moderate Risk • >5 points High Risk Maximum of 22 points possible

38. Discussion Question #17 What dietary recommendations would be appropriate given Mrs. H’s current reported diet and health history?

39. Increase calories • Increase calcium: lowfat milk, cottage cheese, supplements? • Increase protein: legumes, fish, poultry, meat, dairy, eggs • Increase daily servings of vegetables and fruit • Decrease salt intake if salt-sensitive • Only consider liquid protein shake (Boost etc.) if other measures fail or patient prefers and has resources. Carnation Instant Breakfast or soy-based protein powders are good alternates.

40. Treatment Algorithm • Wallace JI, Schwartz RS. Epidemiology of weight loss in humans with special reference to wasting in the elderly. International Journal of Cardiology. 2002/9 2002;85(1):15-21.

41. Discussion Question #18 • Which of the following are appropriate next steps in the management of Mrs. H?

42. Perform a physical examination • Ask about her instrumental activities of daily living • Administer a standardized depression-screening instrument • Possibly refer her to a social worker • Possibly refer her to an RD • Possibly refer her for a more formal psychiatric evaluation • …..She is referred to a psychiatrist, MSW and an RD and…

43. The geriatric psychiatrist confirms the diagnosis of depression and begins counseling but decides to hold off on medication to see how she progresses. • The MSW refers Mrs. H to a senior citizen center in her neighborhood where she begins to get lunch daily and home delivered meals on the days she cannot attend. The physiatry consult recommends twice weekly physical therapy in the home working on strengthening and flexibility. • The RD works with Mrs. H on simple menus and recipes. • When you see Mrs. H for her follow-up in two months she reports improved mobility, appetite and sleep. Her weight has stabilized and she tells you about two new friends she has made at the senior citizen center.

44. Conclusions for Malnutrition and Weight Loss: • All elderly patients should be nutritionally assessed at least once a year and more frequently if weight loss or malnutrition are present. • Mortality increases dramatically with unintentional weight loss but unintentional weight loss in the elderly is generally treatable and often due to depression, poor access to food, poor dentation or dysphagia rather than maligancies.

45. Lawton Instrumental Activities of Daily Living Scale • Use of the telephone (look up numbers, dial, answer): independent • Traveling via car or public transportation: needs some assistance • Food or clothes shopping (regardless of transport): needs some assistance • Meal preparation: currently independent but could use some assistance • Housework: currently independent but could use some assistance • Medication use (Preparing and taking correct dose): independent • Management of money (write checks, pays bills): dependant- niece takes care of the bills This scale has three possible evaluations for each of the seven questions: independent, needs some assistance, or dependent. Each item is evaluated individually.

46. Depression Screening Instrument: Mood Scale: Short Form Choose the best answer for how you have felt over the past week) • Are you basically satisfied with your life? YES • Have you dropped many of your activities and interests? YES • Do you feel that your life is empty? NO • Do you often get bored? YES • Are you in good spirits most of the time? NO • Are you afraid that something bad is going to happen to you? YES • Do you feel happy most of the time? NO • Do you often feel helpless? YES

47. Mood Scale continued • Do you prefer to stay at home, rather than going out and doing new things? YES • Do you feel you have more problems with memory than most? NO • Do you think it is wonderful to be alive now? NO • Do you feel pretty worthless the way you are now? YES • Do you feel full of energy? NO • Do you feel that your situation is hopeless? YES • Do you think that most people are better off than you are? YES A score greater than 5 points is suggestive of depression and should warrant a follow-up interview. Scores greater than 10 points are almost always depression. Mrs. H scores a 12!

48. Symptoms of Major Depression • Weight loss of 5% of body weight in 1 month • Loss of appetite • Insomnia or hypersomnia • Psychomotor agitation or retardation • Fatigue or loss of energy • Feelings of guilt or worthlessness • Diminished concentration • Suicidal thoughts • Loss of interest.

49. “I’m A Meat And Potatoes Man”Geriatric Nutrition Case #2:Hypertension, Stroke and DysphagiaCJ Segal-Isaacson, EdD RD • Case: Mr. Edwards is a 73-year-old man that you are seeing for the first time at the clinic because his previous primary care provider has recently retired. He is feeling well and presents to the office today for a routine initial visit. He has a history of hypertension, but denies chest pain, shortness of breath, palpitations, and dyspnea on exertion, fatigue or any other symptoms.

50. Physical Examination • Height: 69 inches; Weight: 190 lbs.; BMI 28.1 • Pulse: 68 regular RR: 18 • BP: 140/95 • Gen: healthy, well-nourished male, appearing younger than stated age with somewhat poorly controlled hypertension. • Social History • Mr. Edwards is married and lives in his own home with his third wife of 2 years. He has two grown children, both married. He is retired and living off his pension, investment income and social security income. • Medications • Atenolol, 50 mg OD • Metamucil 1 tablespoon daily