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http://www.aecom.yu.edu/nutrition/presentation/Presentation.htm
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.
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
Im 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 54 tall and weighed 174 lbs (BMI 29.9 kg/m2) 3 months ago. Today she weighs 154 lbs (BMI 26.4 kg/m2).
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.
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 communitydwelling 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.
1. 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.
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?
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
1. 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.
Discussion Question #6
What are some of the causes of inadequate food intake in the elderly?
The Nine Ds of Inadequate Food Intake and Weight Loss In The Elderly:
Disease Depression Drugs Dementia Dysphagia Dentition Dysgeusia Dysfunction Diarrhea/Malaborption
When etiology is established the most frequent reasons are: Depression GI (peptic ulcer or motility disorders) Cancer
Diagnostic Algorithm
1.
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.
Discussion Question #9
To recoup: How much weight loss is considered a clinically significant amount to lose over a 12 month period?
1 with b
2 with c 3 with a
Appetite loss:
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 welltolerated 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.
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.
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
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.
Dinner?
Evening Snack?
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
30
40
37
50
44
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. Hs 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.
Developed by Nstles
Increase calories
Increase calcium: lowfat milk, cottage cheese, supplements? Increase protein: legumes, fish, poultry, meat, dairy, eggs Increase daily servings of vegetables and fruit
Treatment Algorithm
1.
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.
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.
Depression Screening Instrument: Mood Scale: Short Form Choose the best answer for how you have felt over the past week) 1. Are you basically satisfied with your life? YES 2. Have you dropped many of your activities and interests?
YES
3. Do you feel that your life is empty? NO 4. Do you often get bored? YES 5. Are you in good spirits most of the time? NO 6. Are you afraid that something bad is going to happen to you? YES 7. Do you feel happy most of the time? NO 8. Do you often feel helpless? YES
10. Do you feel you have more problems with memory than most? NO
11. Do you think it is wonderful to be alive now? NO 12. Do you feel pretty worthless the way you are now? YES 13. Do you feel full of energy? NO 14. Do you feel that your situation is hopeless? YES 15. 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!
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.
Im A Meat And Potatoes Man Geriatric Nutrition Case #2: Hypertension, Stroke and Dysphagia CJ 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.
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
Questions For Discussion: 1. What dietary or other lifestyle modifications would you suggest Mr. Edwards make to help control his hypertension?
2. How would you modify these recommendations if he were obese?
Assessing Dysphagia: Patient sits upright and drinks 30 ml water. Dysphagia if any one of four symptoms: 1. Delayed swallowing 2. Drooling 3. Coughing within 1 minute of swallowing 4. Dysphonia
1. Sitoh YY et al. Singapore Med J. 2000. 41:376-381.
Discussion Question: If Mr. Edwards is found to be dysphagic, how would you recommend feeding him and why?
Interventions for dysphagia in acute stroke By mouth by altering texture of food and positioning of patient. Adjust the consistency of food when necessary by: Thickening liquids (add gels, purees, etc.) Thinning foods and liquids (add water, juice, etc.) Maintain an upright position (as near 90 degrees as possible) whenever eating or drinking.
Try turning the head down, tucking the chin to the chest, and bending the body forward when swallowing. This often provides greater swallowing ease and helps prevent food from entering the airway. Do not mix solid foods and liquids in the same mouthful and do not "wash foods down" with liquids, unless you have been instructed to do so by the therapist. Eat in a relaxed atmosphere and following each meal, sit in an upright position (90 degree angle) for 30 to 45 minutes. Increasing the number of feedings to compensate for smaller meals. Including nutrition supplements such as Boost, Ensure High Protein etc.
PEG Tube
Contra-Indications:
Absolute contra-indication is the inability to access the stomach either endoscopically or trans-abdominally e.g. a large previous gastric resection can be a contra-indication.
Extensive previous abdominal surgery as adhesions may increase the risk of bowel perforation.
The poor general condition of the patient e.g. cardiorespiratory failure. The presence of abdominal skin infection is also a short term contra-indication as this may increase the risk of infection around the PEG tube.
Make sure dysphagic patients are getting adequate calories and nutrients.