Geriatric Malnutrition

1. Geriatric Malnutrition Richard Allan Bettis, Fourth-Year Pharm.D. Candidate Preceptor: Dr. Ali Rahimi University of Georgia College of Pharmacy

2. Background • A frequent and common condition in the elderly associated with: • Increased morbidity • Increased mortality • Increased hospitalizations • Reduced quality of life

3. Frequency • Occurs in 5-10% of older patients residing in nursing homes or long-term care facilities • Occurs in up to 50% of older patients when discharged from the hospital • Most reversible or treatable causes of undernutrition are frequently overlooked by physicians

4. Background • Undernutrition or malnutrition can be a result of two likely scenarios: • Protein energy wasting characterized primarily by weight loss • Individual nutrient deficiencies characterized by a lack of single nutrients and seen more commonly in older persons

5. The Body & Energy • Total energy expenditure based upon an individual’s basal metabolic rate (or BMR) • Energy required for physical activity and creating fuel reserves after feeding • Dependent upon age, weight, gender, and activity level

6. Energy & Aging • BMR decreases with age regardless of constant body weight • Result of muscle tissue replacement by less metabolically active adipose tissue

7. Energy & Nutrients • Protein, carbohydrates, and fat account for a percentage of total calories to meet nutritional needs

8. Energy & Nutrients • Energy yield varies between different types of foods

9. Energy & Proteins • More energy from protein is highly encouraged and supported

10. The Body & Energy • Metabolic fuels in excess of energy expenditure results in obesity • A lack of metabolic fuel to supply energy expenditure results in emaciation, wasting, marasmus, kwashiorkor • Bothsituations are associated with increased mortality

11. Nutrient Deficiency • A lack of single nutrients resulting in less common disease states • Very rarely seen in developed countries except occasionally in older persons

12. Weight Loss & Mortality • When older patients lose weight they have a doubling in their risks for death • Even if the patient is overweight! • Weight loss increases likelihood of: • Hip fractures • Institutionalization • Downward spiral of negative events • Weight loss is the best sign of treatable undernutrition

13. Caregiver Perceptions • Weight loss is the best sign of treatable undernutrition or malnutrition

14. Nutritional Status • There is no gold standard for diagnosis of malnutrition • There are several quick assessment tools

15. Nutritional Assessment Tools • Mini-Nutritional Assessment (MNA) • Most established screening tool for older adults • Difficult to distinguish between patients at risk for malnutrition and frailty • Notapplicable if patients are non-communicable

16. Nutritional Assessment Tools • Simplified Nutritional Assessment Questionnaire (SNAQ) • High sensitivity and specificty to detect weight loss over next 6 months • Malnutrition Universal Screening Tool (MUST) • Uses BMI, weight loss, and an acute disease effect score • Predictor of mortality and length of stay in hospital

17. SimplifiedNutritionalAssessment Questionnaire (SNAQ)

18. Nutritional Assessment Tools • Nutritional Risk Screening (NRS) • Proposed universal screening tool for malnutrition in hospitalized patients • Assesses BMI, weight loss, appetite, and severity of disease • Applicable to more types of patients

19. Nutritional Markers • Serum protein assays • Albumin, prealbumins, retinol binding proteins • Not specific to detect malnutrition or changes in nutritional status • Reductions in these proteins are better indicators of illness

20. Nitrogen Balance • Normally at equilibrium • Intake = output • No change in total body content of protein • Positive nitrogen balance • Growing children, pregnancy, recovery from protein loss • Excretion of nitrogenous compounds is less than intake • Net retention of nitrogen is in the body as protein

21. Nitrogen Balance • Nitrogen balance studies show consuming more than 14% of energy source from protein is more than enough to increase muscle protein synthesis

22. Amino Acids • Essential • Cannot be synthesized in the body • If any of these are lacking, then nitrogen balance will not be possible • Histidine, isoleucine, leucine, lysine, methionine, phenylalanine, threonine, tryptophan, and valine • Non-essential • Can be synthesized from the body or from essential amino acids • Not necessary for nitrogen balance

23. Weight Loss Complications • Severe weight loss leads to protein malnutrition and a downward spiral of adverse effects • Loss of weight also leads to loss of: • Fat • Muscle • Bone • Albumin

24. Weight Loss Cause • A lack of metabolic fuel to supply energy expenditure results in weight loss, emaciation, and wasting

25. Weight Loss Causes • Six major causes of weight loss in older patients: • Anorexia • Cachexia • Sarcopenia • Malabsorption • Hypermetabolism • Dehydration The “Triple Threat”

26. “Anorexia of Aging” • Anorexia is an independent predictor of mortality • Reduction in food intake as individual’s age • Males – 30% • Females – 20% • Causes of anorexia in older patients are multifactorial • Physiological • Psychological • Drug or disease induced

27. “Anorexia of Aging” • Causes of anorexia in older patients are multifactorial • Physiological • Psychological • Depressed or cognitively impaired patients • Disease or drug induced • Decreased appetite due to acute disease or medication effects

28. “Anorexia of Aging” • Physiological changes • Decreasein taste and olfaction resulting in decreased enjoyment of food • Decreasein gastric emptying resulting in early satiation signals • Changesin gut hormones involved in (satiety or feelings of fullness)

29. Gut Hormones

30. “Anorexia of Aging” • Gut hormone changes and contribution to anorexia • Increasein cholecystokinin (CKK) release and sensitivity resulting in greater satiating effects • Increasein leptin levels resulting in increased satiety after meals • Reducedsensitivity to ghrelin associated with reductions in hunger sensation

31. “Anorexia of Aging” Anorexia is multifactoral

32. Causes of Weight Loss • Six major causes of weight loss in elderly: • Anorexia • Cachexia • Sarcopenia • Malabsorption • Hypermetabolism • Dehydration The “Triple Threat”

33. Cachexia • Severe wasting disorder characterized by loss of both fat and muscle • Caused by effects from the overproduction of pro-inflammatory cytokinesresulting from a variety of illnesses • Marked by changes in other markers: • Increases C-reactive protein • Decreases serum albumin • Causes anemia

34. Cytokine Overproduction • Usually overlapped with anorexia and sarcopenia in older individuals • Increases resting metabolic rate resulting in higher metabolic demands • Decreases both gastric emptying and intestinal motility

35. Causes of Weight Loss • Six major causes of weight loss in older patients: • Anorexia • Cachexia • Sarcopenia • Malabsorption • Hypermetabolism • Dehydration The “Triple Threat”

36. Sarcopenia • In Greek, translates literally to “poverty of flesh” • Characterized by muscle atrophy and a loss of muscle functionality • Associated with aging and prevented by exercise

37. The “Triple Threat”

38. Causes of Weight Loss • Six major causes of weight loss in older patients: • Anorexia • Cachexia • Sarcopenia • Malabsorption • Hypermetabolism • Dehydration

39. Malabsorption • Most commonly caused by celiac disease and pancreatic insufficiency in older patients • Serum levels of vitamin A and beta-carotene used to diagnose fat malabsorption • Screenings for various immunoglobins and antibodies used to diagnose celiac disease

40. Causes of Weight Loss • Six major causes of weight loss in older patients: • Anorexia • Cachexia • Sarcopenia • Malabsorption • Hypermetabolism • Dehydration

41. Hypermetabolism • When energy demand exceeds nutrient intake • Most commonly caused by hyperthyroidism and pheochromocytoma in older patients

42. Hypermetabolism • Apathetic hyperthyroidism • Weight loss • Atrial fibrillation • Proximal muscle weakness • Blepharoptosis (not exophthalmos) • Pheochromocytoma • Adrenal gland tumor • Consider if hypertensive and losing weight

43. Causes of Weight Loss • Six major causes of weight loss in older patients: • Anorexia • Cachexia • Sarcopenia • Malabsorption • Hypermetabolism • Dehydration

44. Dehydration • Reduced total body water • Normal daily fluid requirement is 30ml/kg body mass

45. “Anorexia of Aging” • Causes of anorexia in older patients are multifactorial • Physiological • Psychological • Drug or disease induced

46. “Anorexia of Aging” • Psychological manifestations • Reactive depression • Change in living conditions • Food refusal behaviors • All are not uncommon and can lead to weight loss and malnutrition

47. Depression • Most common cause of treatable anorexia in community and institutional settings • Late-life depression is significantly underdiagnosed in older persons • Corticotropin-releasing hormone (an anorexogenic) is elevated in patients with depression

48. Relocation • Change in living conditions evokes psychological anorexic responses • Late-onset paranoia • Fear of poisoning • Indirect self-destructive behavior (ISDB) • An unconscious method of suicide • May be due to trauma of relocation

49. Food Refusal Behaviors • Most prevalent in cognitively impaired • Common in demented elderly patients due to agnosia or dyspraxia • Difficulty interpreting sensory data and not recognizing an object as food • Difficulty with motor movements and unable to open mouth despite intentions to • Common refusal behaviors in intermediate-stage Alzheimer’s patients would be: • Distraction from eating • Verbal refusal to eat

50. Food Refusal Behaviors • Deliberate refusal • Indirect self-destructive behavior (ISDB) • Reflexive withdrawal behavior • Dislike of a certain food • Protest against certain caregiver • It is crucial to distinguish between refusal to eat and lack of ability to eat • Patients with dysphagia may refuse food