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 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

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?

Demographics

Malnutrition

Independent 0-6% Skilled Care 2-27% Hospital 10-30%, up to 75%

Stay is longer with more malnutrition

MACRONUTRIENTS I

Water

8 x 8 oz/d

30ml/kg/d or 1ml/kcal eaten

carbs from whole grains

Carbohydrates 55-60% total kcal/d

Proteins 1 to 1.5 gm/kg/d Fats <30% total kcal/d Cholesterol < 300 mg/d Fiber > 4 gm/d

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

Micronutrients

Vitamins, Co-factors Minerals Trace Elements

Multivitamin Multivitamin Multivitamin

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

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 Normal weight Overweight Obesity Extreme Obesity

<18.5 18.5-24.9 25-29.9 >= 30 >= 40

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

BMI Height 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 91 94 97 100 104 107 110 114 118 121 125 128 132 136 140 144 148 152 156 96 99 102 106 109 113 116 120 124 127 131 135 139 143 147 151 155 160 164 100 104 107 111 115 118 122 126 130 134 138 142 146 150 154 159 163 168 172 105 109 112 116 120 124 128 132 136 140 144 149 153 157 162 166 171 176 180 110 114 118 122 126 130 134 138 142 146 151 155 160 165 169 174 179 184 189 115 119 123 127 131 135 140 144 148 153 158 162 167 172 177 182 186 192 197 119 124 128 132 136 141 145 150 155 159 164 169 174 179 184 189 194 200 205 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 Body Weight (pounds) 124 128 133 137 142 146 151 156 161 166 171 176 181 186 191 197 202 208 213 129 133 138 143 147 152 157 162 167 172 177 182 188 193 199 204 210 216 221 134 138 143 148 153 158 163 168 173 178 184 189 195 200 206 212 218 224 230 138 143 148 153 158 163 169 174 179 185 190 196 202 208 213 219 225 232 238 143 148 153 158 164 169 174 180 186 191 197 203 209 215 221 227 233 240 246 148 153 158 164 169 175 180 186 192 198 203 209 216 222 228 235 241 248 254 153 158 163 169 175 180 186 192 198 204 210 216 222 229 235 242 249 256 263 158 163 168 174 180 186 192 198 204 211 216 223 229 236 242 250 256 264 271 162 168 174 180 186 191 197 204 210 217 223 230 236 243 250 257 264 272 279 167 173 179 185 191 197 204 210 216 223 230 236 243 250 258 265 272 279 287

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.

Anthropometrics III : Research tools

Skin fold and mid-arm circumference Water Displacement Bioelectrical Impedance Dual Radiographic Absorptiometry CT MRI Total Body 40K

Wasting and Cachexia

Wasting - Severe weight

loss and diminished nutritional intake

Cachexia - Inflammatory
cytokine mediated wasting

Semistarvation Reduced metabolic demand Visceral protein sparing Obvious weight loss

Semistarvation overlap Increased metabolic demand Visceral protein wasting ECF incr masks weight loss Limited response to antiinflammatory/anabolics Nutritional intervention slows semistarvation part

RA, CHF, COPD, HIV, Critical care without nutritional support

Marasmus, CA, HIV with opp inf, critical care without nutritional support, chronic organ failure

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

Failure to Thrive

Not a defined syndrome in the elderly

DETERMINE Screening Tool

D E T E R M I N E

isease ating poorly ooth loss, mouth pain conomic hardship educed social contacts ultiple medications nvoluntary weight loss or gain eed for assistance in self-care lderly (age > 80)

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 I eat fewer than 2 meals a day I eat few fruits or vegetables, or milk products I have 3 or more drinks of beer, liquor, or wine almost every day I have tooth or mouth problems that make it hard for me to eat I dont always have enough money to buy the food I need I eat alone most of the time I take three or more different prescribed or over-the-counter drugs a day Without wanting to, I have lost or gained 10 pounds in the last 6 months I am not always physically able to shop, cook, and /or feed myself 2 3 2 2 2 4 1 1 2 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,

Mini-Nutritional Assessment (MNA)

Two Part

3 min screen 8 min diagnostic

Validated against measurable standards Inclusive, Plenary

MNA Part 1 Skill Session

MNA Part 2 Skill Session

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

Alzheimers

Supplementation at 2 kg weight loss stabilizes weight loss compared to controls

Food Pyramids

MyPyramid.gov Culturally distinct More flexible

MyPyramid.gov

Grains gold Vegetables green Fruits red Oils yellow Milk Blue Meats + Beans Purple Discretionary Calories

< 200 to 300 kcal 30, 60, 90 rule

Exercise

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

Nutrient-Nutrient/Drug Interactions

Numerous Ca, Mg, Fe Phytins (in fiber) Tannins (coffee, tea)

Bind drugs/nutrients Bind drugs/nutrients Bind drugs/nutrients

Drug-Nutrient Interactions I

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 Interaction II

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

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!

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.

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?

Nutrition Requirement Calculations 1

Estimated Energy Needs by Weight

25-30 kcal / kg body weight / day Use 120% IBW for obese persons
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.

Estimated Protein Needs by Weight

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)

Laboratory Evaluation

Albumin < 3.8 g/dl

Lacks sensitivity and specificity May decline very slightly with age Negative acute phase reactant Shorter half-life than albumin No more predictive
Indicates underlying serious disease in community, hospital and NH patients

Prealbumin

Cholesterol < 160 mg/ml

Total Lymphocyte Count < 2000 cells/microliter

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

TPN

For non-functioning GI tract No EMB studies in elders

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?

Re-feeding Syndrome

Syndrome of

hypophosphatemia hypomagnesemia fluid retention about 3 days into re-feeding

Occurs with oral re-feeding as well

Most pronounced with parenteral nutrition

More severe with worse malnutrition Frequent subclinical presentation Reduce re-feeding rate for three days to treat

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 ADLs. She has no appetite.

Anorexia

Drugs Anemia Uremia Liver Disease Dry Mouth Pain

Cancer Inflammation Psychiatric Illness Bowel Disease Constipation Malnutrition

Anorexia : Appetite Stimulation

Food Appearance Salt Sugar Social Contact Feeding Ambience Familiarity Drugs Ghrelin, other hormones

Anorexia : Pharmacologic Support

Mirtazipine

probably works No therapeutic effect or use in medicine Unsure, probably in depression Probably risk of DVT is too high for routine use Especially in cancer, hematologic, neurologic

Cannabis, Cannabinoids, Tetrahydrocannabinol and its derivatives

Ritalin

Estrogens/Progestins/Thalidomide

Corticosteroids

Prokinetics Cyproheptadine Hydrazine sulphate no utility Dronabinol Antiserotonergic drugs Branched-chain amino acids, Eicosapentanoic acid Melatonin

Sarcopenia of the Elderly

Age related loss of skeletal mass

Type I fibers spared Type II loss of number and size

Sedentary Dietary Hormonal Neurologic Sex hormonal

Questions:

Case Phase 4

Recovers

ICD-9 Codes

Malnutrition

1st degree (mild) 2nd degree (moderate) 3rd degree (severe) (protein calorie) From neglect Causes problems for NH

263.1 263.0 262 995.84

Hypoalbuminemia / Hypoproteinemia Protein Deficiency / Kwashiorkor Marasmus

273.8 260 261 797 569.89 994.2 269.9 269.9 783.21 783.7

Causes problems for NH

Senile Marsmus Intestinal Marasmus Lack of Food Nutritional Deficiency, particular, specify Undernourishment/Undernutrition Weight loss (cause unknown) Failure to thrive

Causes problems for NH

Treatment of Malnutrition

Ease dietary restrictions Supplements

Foods Enhanced Milk or Soy based products

Drugs Supportive Therapies

Summary

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

Bibliography

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 Society 53 (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 Society 51 (7), 1007-1011. doi: 10.1046/ j.1365-2389.2003.51317.x http://www.nhlbi.nih.gov/guidelines/obesity/bmi_tbl2.htm

Journal of the American Geriatrics Society Volume 52 Issue 10 Page 1702 - October 2004 doi:10.1111/j.1532-5415.2004.52464.x

Persson, Margareta D., Brismar, Kerstin E., Katzarski, Krassimir S., Nordenstrm, Jrgen & Cederholm, Tommy E. (2002) Nutritional Status Using Mini Nutritional Assessment and Subjective Global Assessment Predict Mortality in Geriatric Patients. Journal of the American Geriatrics Society 50 (12), 1996-2002. doi: 10.1046/j.1532-5415.2002.50611.x

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Palliative Care Program, Edmonton General Hospital, Canada CA Cancer J Clin. 2002 Mar-Apr;52(2):72-91.

Cancer anorexia-cachexia syndrome: current issues in research and management. Inui A.

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