Transcript Geriatric Nutrition Presentation

Geriatric Nutrition
http://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
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.
• 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
“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).
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.
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?
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.
• 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
Dentition
Depression
Dysgeusia
Drugs
Dysfunction
Dementia
Diarrhea/Malaborption
Dysphagia
•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
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?
• 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?
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.
Discussion Question #10
Match the side effects associated with the medications Mrs. H is
taking.
1.Zocor
2.Norvasc
3.Atenolol
a. depression
b. hepatitis
c. peripheral edema
1 with b
2 with c
3 with a
Discussion Question #11
Which of the following medications may cause loss of
appetite in the elderly?
•
•
•
•
•
•
NSAIDS
Psuedoephedrine
Theophylline
Megestrol Acetate
Antineoplastics
Antihistamines
•Appetite loss:
– Psuedoephedrine, Theophylline, Antineoplastics.
•Increased appetite:
– NSAIDS, “Megace” and Antihistamines.
Discussion Question #12
• Is there an appetite stimulant we should consider
prescribing to Mrs. H? If so, what are they?
• 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):195198.
– 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
– 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.
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.
Discussion Question #13
• Approximately how many calories is Mrs. H eating each
day?
– Breakfast?
– Lunch?
– Dinner?
– Evening Snack?
Total: On a good day, maybe 1000 calories!
– Breakfast: ~200 calories
– Lunch: ~200-300 calories
– Dinner: ~200-300 calories
– Evening Snack: ~ 200 calories
Discussion Question #14
What formula could we use to quickly estimate Mrs. H’s total
daily caloric requirements?
• 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)
Calculating Energy Requirements
Activity Level
Men
kcal/KG
Women
kcal/KG
Light
(also use if patient is
elderly or overweight)
30
30
Moderate
40
37
Heavy
(also use if patient is
underweight)
50
44
Discussion Question #15
What formula should we use to calculate Mrs. H’s ideal
protein intake?
• 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.
Discussion Question #16
• What are some other instruments for assessing diet and
physical activity?
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
Determine Your Health Nutrition Screening Tool
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
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.)
How To Score Nutrition Screening Tool
• 1-2 points
• 3-5 points
• >5 points
Low Risk
Moderate Risk
High Risk
Maximum of 22 points possible
Discussion Question #17
What dietary recommendations would be appropriate given Mrs.
H’s current reported diet and health history?
• 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.
• 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.
Discussion Question #18
•
Which of the following are appropriate next steps in the
management of Mrs. H?
•
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…
• 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.
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.
Lawton Instrumental Activities of Daily Living Scale
1. Use of the telephone (look up numbers, dial, answer):
independent
2. Traveling via car or public transportation: needs some assistance
3. Food or clothes shopping (regardless of transport): needs some
assistance
4. Meal preparation: currently independent but could use some
assistance
5. Housework: currently independent but could use some assistance
6. Medication use (Preparing and taking correct dose): independent
7. Management of money (write checks, pays bills): dependantniece 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.
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
Mood Scale continued
9. Do you prefer to stay at home, rather than going out and
doing new things? 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!
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.
“I’m 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
• Dietary and Other Lifestyle Habits:
– He would prefer not to change his medications.
– He’s a “meat and potatoes” man with less than 3 small
servings of vegetables per week and approximately one
serving of fruit (as OJ) per day.
– He denies smoking cigarettes but admits to smoking a cigar
approximately 2-3x/mo.
– He drinks 3-4 glasses of scotch and soda a day.
– He enjoys walking 2-3 miles per day for exercise.
•
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?
3. Would you prefer to counsel him yourself or refer him to a
dietitian?
The DASH Diet
2000 Calorie Version of DASH Eating Plan
Grains and grain products 7–8 Servings Per Day
1 slice bread, 1 oz dry cereal*, 1/2 cup cooked rice, pasta or cereal
Vegetables 4–5 Servings Per Day
1 cup raw leafy vegetable, 1/2 cup cooked vegetables, 6 oz. vegetable
juice.
Fruits 4–5 Servings Per Day
6 oz fruit juice, 1 medium piece fruit, 1/4 cup dried fruit, 1/2 cup fresh,
frozen or canned fruit.
Lowfat or fat free dairy 2–3 Servings Per Day
8 oz milk, 1 cup yogurt, 1.5 oz cheese
Meats, poultry, 2 or less Servings Per Day
3 oz cooked meats, poultry or fish
Nuts, seeds, and dry beans 4–5 Servings Per Week
1/3 cup,1.5 oz nuts,2 Tbsp or 1/2 oz seeds or 1/2 cup cooked dry beans
and peas
DASH Diet cont.
Fats and oils 2–3 Servings Per Day
1 tsp soft margarine, 1 Tbsp lowfat mayonnaise, 2 Tbsp light salad
dressing or 1 tsp vegetable oil
Sweets 5 Servings Per Week
1 Tbsp sugar, 1 Tbsp jelly or jam jam, 1/2 oz jelly beans beans, hard
candy, 8 oz lemonade, fruit punch or soda
Hypertension, Stroke and Dysphagia cont.
• The Next Three Years…
– For the first year after your initial visit, Mr. Edwards makes
approximately 50% of the changes you ask him to and
regularly comes to the clinic for his check-ups. His blood
pressure 6 months after his initial visit with you is 130/87
with no change in hypertensive medications.
– He slowly begins to backslide, is lost to follow-up and does
not come to the clinic for the next three years.
– Your next contact with him is at the ICU after a severe stroke
leaves him partially paralyzed on his left side and mildly
aphasic.
Hypertension, Stroke and Dysphagia cont.
Discussion Question:
1. Is Mr. Edwards also dysphagic? If the speech therapist is
not immediately available, what is a basic and safe
technique to assess this at his bedside?
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.
• Take small bites -- only 1/2 to 1 teaspoon at a time.
• Eat slowly. It may also help to eat only one food at a time.
• Avoid talking while eating.
• If one side of the mouth is weak, place food into the stronger
side of the mouth. At the end of the meal, check the inside of
the cheek for any food that may have been pocketed.
• 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.
– Nasogastric Feeding Tube
– Percutaneous endoscopic gastrostomy tube (PEG)
– TPN???
PEG Tube
• Indications for a PEG Tube
– Patients who have been unable to eat adequately for at least
5 days and who are likely to require the tube for at least 3 to
4 weeks.
– Patients who are fully or partially unconscious and unable to
eat.
•
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.
Conclusions for Hypertension, Stroke and Dysphagia
• Use the DASH Diet to treat hypertension. Refer person to a
dietitian for counselling if at all possible.
• Regularly assess and monitor compliance with meds and
diet with hypertensive patients.
• Stroke patients should be assessed for dysphagia. Acute
dysphagia may require a feeding tube.
• Chronic dysphagia may require textural modifications to
food and in extreme cases, a feeding tube.
• Make sure dysphagic patients are getting adequate
calories and nutrients.