Nutritional Disorders in geriatry

dr. Iwal Reza Ahdi SpPD

 Case
• 80 year old female
• Severely demented, diabetic, hypertensive,
hyperuricemic, with stage 4 chronic kidney
disease from diabetic nephropathy
• History of fragility fracture on left upper
humerus
• 3 episodes of pneumonia in the last 8
months
• Frequent episodes of abdominal bloating with
frequent watery stools
• Fed with blenderized food 4x a day per NGT,
about 1½ cups per feeding; components
variable
• Actual consumption of feeding: about 70-80%
according to the caregiver
• Has about 15 medications, including calcium
carbonate, ferrous sulfate, amlodipine,
metformin, oral rivastigmine and bisacodyl
• Actual body weight 38 kg, measured height
151 cm
• (+)angular cheilitis and oral ulcers
• (+)oral thrush
• Distended and tympanitic abdomen
• (+)grade II pressure ulceration on sacral
area
 Which of the following
contributes to possible
malnutrition in this patient?
A. Dementia
B. Chronic kidney disease
C. Dysphagia
th e m !
D . C onsti

pa!tion
E. Calcium carbonate
F. Blenderized feeding
G. Lack of vitamin
 Outline

• Prevalence
• Approaching Nutritional Disorders
– Calories and Nutrients
– the Nutrition Pathway
• Management
 Consequences
• Increased morbidity and mortality
– Pneumonia
– Pressure ulceration
• Increased rates of readmission
• Increased rates of institutionalization
• Increased length of hospital stay
• Increased cost of care

Nutr Clin Pract 2010 25: 548

 Not too
easy to
Calories hit!!

Micronutrients Macronutrients
 Dilemmas
• Calories
– How much to actually give
– Guides to base caloric estimation
• Macronutrients
– Disease
– Multiple co-morbiditiesdifficulty in striking a balance
• Micronutrients
– Disease
– Not all can be measured
– Not all have obvious clinical signs of deficiency or toxicity
Cognition and Behavior for
eating
Recognition of hunger
and when to eat
Recognition of what to
eat
 Appreciation of the
food
Ability to actually
prepare food or
communicate this to
Dementia
Vegetative/Comatose
states
Stroke
 Drugs that can cause ANOREXIA

• digoxin • narcotic analgesics

• phenytoin • K+ supplements
• SSRI’s / lithium • furosemide
• Ca++ channel blockers • ipratropium bromide
• H2 receptor antagonists • theophylline
/ PPIs • spironolactone
• Any chemotherapy • levodopa
• metronidazole • fluoxetine
Senses for eating
Underlies appreciation of the
food being eaten
 Includes predominant senses
of sight, smell and taste
Physiologic changes with
aging + pathologic changes
with disease can affect overall
appreciation of food

Physiologic decline in taste,

smell and sight
Dementia
Vegetative/Comatose states
Stroke
Acute disease
Medications
 Drugs That Interfere With Gustation (taste) and
Olfaction (smell)
Gustation Olfaction
• Allopurinol • Amitriptyline
• Amitriptyline • Codeine
• • Dexamethasone
Ampicillin
• Enalapril
• Baclofen • Flunisolide
• Dexamethasone • Flurbiprofen
• Diltiazem • Hydromorphone
• Enalapril • Levamisole
• Hydrochlorothiazide • Morphine
• Imipramine • Pentamidine
• Labetalol • Propafenone
• Mexiletine
• Ofloxacin
• Nifedipine
• Phenytoin
• Promethazine
• Propranolol
• Sulfamethoxazole
• Tetracyclines
Chewing and Swallowing
 Dysphagia
 Cognitive
 Neurologic
 Muscular
 Dental
Remains poorly recognized
and diagnosed

Age-related deterioration in
dentition and muscle strength
Dementia
Vegetative/Comatose states
Stroke, neuropathies and other
neurological conditions
Dietary considerations
 Stages of Swallowing
• Oral
– Weak tongue and jaw muscles
– Uncoordinated movement
– No movement
• Pharyngeal
– Weakness or paresis of muscles
– Uncoordinated movements
• Esophageal
– Weak peristaltic movements
– Esophageal spasms
• Primary condition
• Secondary to pain (e.g. in reflux esophagitis or ulceration)
 Dysphagia Prevalence

• As much as 15% in the elderly population

• As much as 37.6% in community-dwelling
elderly

Clinical Interventions in Aging 2012:7 287

Movement and Digestion of
Food
Physiologic changes with
aging
Decreased rate of
epithelialization
Decreased gastric
compliance
Decreased peristalsis
resulting in increased
intestinal transit
 Changes in digestive
enzyme secretion
Superimposed pathologic and
pharmacologic effects
• Obstruction of GI tract
– Malignancies
• Impairments in mucosal integrity and function
– Atrophic gastritispernicious anemia
– Lactose intolerance
• Deficiencies in digestive enzyme secretion
– Chronic pancreatitis
– s/p cholecystectomy
• Altered gastric motility
– Diabetic gastroparesis
– Chronic constipation and fecal impaction
– Drug effects (e.g. morphine, calcium channel blockers)
• Altered gastrointestinal capacitance and transit
– Gastrointestinal reconstruction (e.g. bariatric surgery or
Roux-en-Y procedures)
Nutrient Absorption
Defects may be preceded by
problems in digestion
 May be complicated by
structural GI changes
 Changes in transit time
 Changes in absorptive
surfaces

Pernicious anemia
Post-surgical states (e.g.
colectomy, bariatric
surgery, short bowel
syndrome) Drug effects
 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
 Drug-Nutrient Interaction
Drug Reduced Nutrient Availability
Alcohol Zinc, vitamins A, B1, B2, B6, folate, vitamin B12
Antacids Vitamin B12, folate, iron, total kcal
Antibiotics, broad-spectrum Vitamin K
Digoxin Zinc, total kcal (via anorexia)

Diuretics Zinc, magnesium, vitamin B6, potassium, copper

Laxatives Calcium, vitamins A, B2, B12, D, E, K
Lipid-binding resins Vitamins A, D, E, K
Metformin Vitamin B12, total kcal
Phenytoin/Salicylates Vitamin D, folate/Vitamin C, folate
SSRIs Total kcal (via anorexia)
Trimethoprim Folate
Overall Nutrient Metabolism
Related to my physiologic
changes
 Kidneys
 Liver
 Changes in body fat and
water percentages
Chronic disease necessitating
dietary modification
Altered nutrient utilization as
a result of disease states
 Dietary Modifications in Chronic
Illnesses
• Non-dialyzed chronic kidney disease
– Protein requirement: as low as 0.6g/kg of protein
– Low potassium, low phosphorus, low purine
• COPD patients
– Low carbohydrate diets previously ordered
– Calories directly related to carbon dioxide output
vs. high-energy expenditure state
• Liver cirrhosis
– Low protein diets, branched chain amino acids
 Management

• comprehensive geriatric management

• an interdisciplinary approach
• multimodality interventions
Comprehensive Geriatric
Examination
• Detailed History
• Physical and

Neurologica
l
Examination
• Cognitive
Evaluation
• Behavioral/Emotiona
l Evaluation
• Functional Evaluation
• Physical manifestations of nutrient
deficiencies in the older patient may be
difficult to detect (particularly vitamin
deficiencies)
• Deficiencies usually occur in combination
(both as caloric, macro and micronutrient
deficiencies)
• Toxicities may be even more difficult to
detect
 Diagnostics
• CBC
• FBS, kidney, liver and thyroid function tests
• Albumin (interpreted cautiously)
• Lipid profile
• Urinalysis
• 12-L ECG, CXR, 2D-echo
• Fecalysis
• Inflammatory markers?
• Vitamin assays?
• Calorimetry?
• Other specialized tests?
 Interdisciplinary Approach
• Primary physician/s (Geriatrician, Internist, Family
Physician, Others)
• Neurologists
• ENT specialists
• Gastroenterologists, Surgeons
• Physiatrist
• Physical, Occupational, Speech and Swallowing
Therapists
• Nurses
• Nutritionist
• Pharmacist
 Multimodality Interventions
• Medical interventions
• Drug reviews and monitoring
• Nutritional Management
• Physical, Occupational, Swallowing and
Speech Therapy
• Artificial Enteral Feeding
• Parenteral Feeding???
 Nutritional Management
• Dietary Prescription
– Tolerance
– Adequacy of prescription and response
• Use of nutritional supplements
– Tolerance
– Cost vs. benefit
 Therap
y
• Individualized approach
• Challenges
– Assessment
– Intervention application
– Response and limitations
 Artificial Enteral Feeding

• Nasogastric feeding
• Gastrostomy
• Enterostomy
 Summary
• Nutritional disorders are common in chronic disease
• Aside from viewing nutritional disorders as those
affecting calorie, macronutrient and micronutrient
intake, it can be viewed as to the level along the
nutrition pathway at which these develop
• Medications play a significant part in nutritional
disorders
• Comprehensive geriatric management, an
interdisciplinary approach with multimodality
interventions are needed