Transcript nutrition across the continuum including at the end of life

NUTRITION ACROSS THE CONTINUUM
INCLUDING AT THE END OF LIFE
Bindhu Thomas, M.D., C.M.D
Division of Geriatric Medicine and Aging
Columbia University College of Physicians and Surgeons
Goal
To familiarize the participants with risk factors for
compromised nutritional status older adults face as they
traverse the continuum of care
To familiarize the participants with aspects of nutrition at
the end of life, dilemmas, and concepts of palliative,
hospice care
A Sobering Trend Line
Objectives
1. Identify 8 main categories of nutritional risk factors
2. Name one risk factor from each category for each
venue of care
3. Name 1 difference between palliative and hospice
care
4. Give 2 reasons why patients are not referred for
Palliative or Hospice Care
5. Things patients with serious illness want?
Homeostasis
Homeostenosis
WHAT IS THE CONTINUUM
•THE COMMUNITY……..
•THE HOSPITAL…………
•HOMEBOUND…………..
•THE LONG TERM CARE FACILITY….
Geriatric Nutrition
• Body weight is a simple screen for nutritional adequacy
• Avolitional weight loss is predictive of mortality in older
adults
• At high risk for malnutrition
• 71 % hospitalized patients are at nutritional risk or
malnourished
• Changes with normal aging
• Diminished organ system reserves
• Weakened homeostatic controls
• Increased heterogeneity among individuals
Gastrointestinal System
• Broad series of changes
• Symptoms are usually delayed
GI System
• Slower production of
dentine
• Root pulp shrinkage
• Jaw bone density ↓
• Taste and Smell ↓
• Salivary gland function ↔
• Tongue appears larger
• Esophagus fxn normal
• Muscular contraction and
peristaltic wave decrease
• Less acid secretion
• Decreased gastric emptying
• Liver weight declines
• Reduction in small intestine
surface area
• Decline in Colonic function
• Motility to rectosigmoid area
not affected
• Distally ..its slowed
• Stool frequency declines
• Hardness increases
• Diverticula increases
Age Related GI Syndromes
• Peridontal disease
• GERD
• Colon Cancer
• Constipation : 60%
• Sx of obstipation:
• Delirium
• Nausea
• Vomiting
• Gastric empty delay…early satiety
• Hepatic metabolism
• Diverticulosis/diverticulitis
Nutritional Risk Factors
PRIMARY AGING
Normal, disease-free aging across adulthood
Not pathologic in themselves
Slight decrease in function in every organ system
Menopause
Decline in reaction time
Thinning and graying of hair
HALLMARKS
Decreased reserve
Heterogeneity among different people
Variability within different organ systems
SECONDARY AGING
• Diseases and syndromes that are more common in older adults
• Changes due to disease, lifestyle, and environmental factor
HEENT CONDITIONS
Visual impairment (cataracts, macular degeneration, retinopathy)
Decreased auditory acuity
Poor dentition
GI CONDITIONS
Achlorhydria
Diverticulosis/itis / Hemorrhoids
Neoplasias
IBS
PULMONARY CONDITION
COPD
CARDIAC CONDITIONS
 Cardiac cachexia
 Severe CHF
INTEGUMENT/MUSCULOSKELETAL CONDITIONS
 DJD
 Osteoporosis
 Podiatric concerns
NEURO-PSYCH CONDITIONS
 CVA
 Dementia
 Depression
 Parkinson’s
 Delirium
Tertiary Aging
• Psycho-Social, environmental and societal factors occurring more
commonly with aging
Tertiary Aging
• Isolation
• Poverty
• Immobility
• Caregiving
• Lifelong Eating habits
NUTRIENT REQUIREMENTS
Very difficult to generalize
Heterogeneity
Extrapolated
Based on healthy people
NAS/NRC decrease caloric intake by 10%
Protein should be .8 – 1 g/kg/d
Nutrient Requirements
Calculating Caloric Need
Low stress:
Moderate stress
Severe stress
20 kcal/kg/d
25-30kcal/kg/d
35kcal/kg/d
Nutrient Deficiencies
• Most often seen in older adults who have other risk factors or
who are acutely ill
• Seen in older adults who live alone in the community, on a
budget, and have multiple comorbidities
Nutrient Excess
50% of adults >60 years are now obese
Metabolic syndrome
Abdominal obesity >102 cm men >88cm women
Triglycerides > 150 mg/dl
HDL < 40 men, 50 women
BP > 130/85 mm Hg
Fasting glucose >110 mg/dl
Nutrient Excess
EFFECTS OF NUTRIENT EXCESS
Total intake: Obesity, HTN, DM, DJD
Vitamin A : Anorexia, xeroses, hypercalcemia
Vitamin E : Hemorrhage, GI distress, K metabolism
Vitamin C : Diarrhea, renal oxalate calculi, B12
absorption, false negative hemoccult
ALCOHOL
Smaller volume of distribution  higher blood levels
Increased tissue sensitivityCNS effects
Multiple drug-ETOH interactions
7kcal/gm; no other nutritive value
MEDICATIONS
Symptom
Anorexia
Medication effects on nutritional status
Medications
Digoxin, antibiotics,
narcotic analgesics
Xerostomia
psychotropic, anticholinergics
diuretics, antihistamines,
Diarrhea
laxatives, psychotropic, sertraline
Nausea, vomiting
Digoxin, narcotic analgesics,
chemotherapeutic agents, antibiotics,
NSAIDs
FLUIDS
HYPODIPSIA
Decreased vasopressin response
Thirst derangement
 oropharyngeal sensation
 baroreceptor sensitivity
 osmoreceptor sensitivity
Antidipsogens:  agonists, dopamine antagonists, ANF
Case: Ms. D
• 86yo woman with PMH DM, HTN, HLD and dementia
• Previously living in her own apartment with 24hr HHA
• Fall-broken right hip
• S/P repair
• Unable to return home after surgery
• Discharged to nursing home
Case
• Episodes of delirium after surgery
• Unable to walk, mostly in bed or wheel chair
• Decreased interest in food
• Readmitted to hospital
• Declining mental status, but still seems to enjoy visits from
family
• Family is deeply troubled by her not eating
Feeding Difficulties in Advanced Dementia
• Very common
• Very difficult for families
• Do not care about food
• Resist food
• Dysphagia
• Aspiration
PEG Tubes
•
•
•
•
Intended to prevent aspiration
Provide nutrition
Prevent weight loss
34% of nursing home patients with
advanced dementia have PEG
tubes
• 2/3 of these tubes were placed
during an acute hospitalization
PEG Tubes Do Not Reduce Risk Of Aspiration
• Oral secretions can still be aspirated
• Do not reduce risk of regurgitating stomach contents, which can
then be aspirated
• Case control studies identified PEG tubes as a risk factor
aspiration pneumonia
• Jejunostomy is not associated with lower rates of aspiration
pneumonia
Tube Feeding Does Not Improve Quality
of Life
• Associated with increased
risk of development of
pressure ulcers
• Increased use of restraints
• More frequent ER trips for
tube-related problems
• Within 1 year of insertion,
almost 20% of patients
required a reinsertion or
repositioning of tube
PEG Tube Placement Does Not Improve Survival
• Risk associated with procedure:
• 2% mortality rate during procedure
• 6-24% mortality rate in perioperative period
• In hospitalized patients with advanced dementia: 50% 6 month
mortality with or without PEG tube
• Median survival after PEG tube placement is 7.5
months
Appetite Stimulants: Orexigenics
• High calorie supplements: Boost
• Megestrol acetate:
•
•
•
•
Progesterone receptor agonist
Appetite stimulant
Contraceptive
Antineoplastic agent
• Dronabinol
• AIDS, Alzheimers, not studied
• Mirtazapine (Remeron)
• Cannabinoids
Appetite Stimulants Do Not Improve Outcomes
• High calorie supplements can increases weight
• However, no improvement in quality of life, functional status,
and survival
• Lack of evidence supporting use of cannabinoids
• Mirtazapine may increase weight and appetite, however no
evidence supporting its efficacy in the absence of depression
• Megestrol acetate shows minimal improvement in weight and
appetite, but…
Megestrol Acetate: Increased Risk From Side Effects
• Increase risk of thrombotic events
• Increased fluid retention
• Increased risk of death
• Recently classified as a medication to avoid in
older adults
• Not recommended by American Geriatric Society
Supportive Measures
• Slow hand feeding as tolerated and desired by patient
• Study showing no difference in survival in demented vs. non-demented
patients in long term care getting slow hand feeding
• Oral feeding promotes socialization between family and patient
Supportive Measures
• Mouth care
• Patients have decreased salivation at end of life
• Significant discomfort from dry mouth
• Ice Chips
• Treat other causes of feeding difficulties
• Constipation
• Depression
• Xerostomia
Reality
• There will come a time when the diet consistencies, orixogenics,
supplements, G, J Tubes will start to fail.
• Body will start shutting down
• You, as the clinician must anticipate this and prepare the patient and
family.
• Prolonging the inevitable is not quality of life
• Key is …????
Cancer Trajectory, Diagnosis to Death
Cancer
Function
High
Low
death
Time
Organ System Failure Trajectory
Function
High
Low
death
Time
Function
High
Dementia/Frailty Trajectory
death
Low
Time
• 85% of people in the US will experience
one of these trajectories at the “end of
life”
20% Cancer
25% Organ Failure
40% Dementia/Frailty
• Key is …????
DIFFICULT DECISIONS
 Are we preserving life or prolonging death?
 When is chemo or radiation therapy palliative in
nature and when is it curative?
 PEG tube placement?
 Do I want to be a DNR-what is a DNR?
 IVF’s? Hemodialysis?
 What is “quality of life”?
Communication with Families
• Speak with patients and
caregivers early about what to
expect and course of illness
• Very high mortality rate in people
with advanced dementia similar to
those with end stage liver disease
or cancer
• Often patient’s families do not
know or understand this
• Start to talk about palliative and
Hospice Care
• Before the Crisis
WHO DEFINITION
“Palliative Care is an approach that improves the quality of life
of patients and their families facing the problem associated
with life-threatening illness, through the prevention and relief
of suffering by means of early identification, and impeccable
assessment and treatment of pain and other problems, physical,
psychosocial and spiritual”
…any illness, any age, any location…
 Palliative care is the active, total care of patients
who are
NOT RESPONSIVE TO CURATIVE
THERAPY
 If you are suffering from a chronic illness you are
probably receiving palliative care.
Hospice Care
• Hospice care focuses on improving the quality of life for persons and
their families faced with a life-limiting illness.
• The primary goals of hospice care are to provide comfort, relieve
physical, emotional, and spiritual suffering, and promote the dignity of
terminally ill persons.
• Hospice care neither prolongs nor hastens the dying process.
• Care is palliative (not curative) to control pain and symptoms
associated with the terminal illness.
Principles of Hospice Care
• Affirms life
• Regards dying as normal process
• Neither hastens nor postpones death
• Relives pain and other symptoms
• Integrates medical, psychological, and spiritual aspects of care
• Offers a support system to patients and
families
When is Hospice Care Appropriate?
• Patient and Family has opted for palliative care and have decided to
forgo curative therapy
• Medicare guidelines further require that the physician has
determined that life expectancy is six months or less if the disease
follows its normal course.
• 2 Doctors have to Confirm the life limiting illness6 months
Who is Eligible for Hospice Care
• Hospice care is not just for patients dying of cancer
• Other hospice diagnoses include:
• End stage heart disease
• End stage pulmonary disease
• End stage renal disease
• End stage liver disease
• Dementia due to Alzheimer’s Disease and Related Disorders
• HIV disease
• Stroke & Coma
Common End Of Life Symptoms
• Pain
• Physical
• Emotional
• Spiritual
• Shortness of breath
• Nausea / vomiting
• Anorexia / Cachexia
• Weakness/ fatigue
• Constipation
• Delirium
What Do Patients with Serious Illness Want?
 Pain and symptom control
 Avoid inappropriate prolongation of the dying
process
 Achieve a sense of control
 Relieve burdens on family
 Strengthen relationships with loved ones
Singer et al. JAMA 1999;281(2):163-168.
Core Aspects of Hospice
• Patient/family focused
• Interdisciplinary
• Provides a range of services:
• Interdisciplinary case management
• Pharmaceuticals
• Durable medical equipment
• Supplies
• Volunteers
• Grief support
Additional Services
• Hospices offer additional services,
including:
• Hospice residential care (facility)
• Inpatient hospice care
• Palliative care
• Complementary therapies
• Specialized pediatric team
• Caregiver training classes
Hospice Team Members
• The patient and family/ caregiver
• The patient’s primary physician
• Hospice physician
• Nurse
• Social worker
• Chaplain
• Hospice aide
• Volunteers
• Bereavement counselor
• Additional team members may include dietician, occupational
or physical therapist, pharmacist
The Hospice Team
• Develops the plan of care
• Manages pain and symptoms
• Attends to the emotional, psychosocial and spiritual
aspects of dying and caregiving
• Teaches the family how to provide care
• Advocates for the patient and family
• Provides bereavement care and counsel for 13
months
Where Hospice is Provided
• Home
• Nursing Facility
• Assisted Living Facility
• Hospital
• Hospice residence or unit
• Prison, homeless shelter – where ever the person
is
How Does Palliative Care Differ From Hospice?
 Non-hospice palliative care




Appropriate at any point in a serious illness.
It is provided at the same time as life-prolonging treatment.
No prognostic requirement
No need to choose between treatment approaches.
 Hospice is a form of palliative care
 Care for those in the last weeks/few months of life
 Patients must have a 2 MD-certified prognosis of <6 months
 Give up insurance coverage for curative/life prolonging treatment in
order to be eligible.
(Medicare Hospice Benefit: 84% Medicare, 5% Medicaid, 3% uninsured)
Conceptual Shift for Palliative Care
Life Prolonging Care
Medicare
Hospice
Benefit
Life Prolonging
Hospice Care
Care
Palliative Care
Dx
Death
Old
New
Palliative Care
All hospice care is palliative, but not all
palliative care is hospice
Hospice
Barriers to Palliative Care
1. Absence of an advance directive
2. Lack of clarity as to when to refer a patient
3. Physician’s reluctance to make referral
4. Lack of physician’s familiarity with the availability or suitability
of hospice
5. Family reluctance to accept palliative care
6. Association of hospice with death
7. Lack of information about the severity of and/or irreversibility
of the patient’s illness
• Few want heroic measures to prolong their
lives. “Subjects who had living wills were
more likely to want limited care (92.7%) or
comfort care (96.2%) than all care possible
(1.9%).”
Silveira, NEJM 2010
What Are Advance Directives?
• A written statement where You are in charge of making your own
decisions
• Wishes, preferences and choices regarding end-of-life health care
decisions
• A tool to help you think through and communicate your choices
• Documents can be changed anytime
• You DO NOT need an attorney
• Documents can help you express your wishes
• FORMS www.caringinfo.org
Why Do We Need Advance Directives?
• Your wishes will be known: AUTONOMY
• Only used if you are unable to express your decisions
• This can happen to anyone – at any age …even You and Me
• Give your loved ones the gift of peace of mind – write down your
wishes!
• According to a national survey done in 2004, 88 percent – feel
comfortable discussing issues relating to death and dying,
• However, only 42% have a living will
Advance Directives
• Health Care Proxy (HCP) = Allows competent adults to appoint an agent to
decide about treatment on their behalf if they become unable to decide for
themselves.
• Living Will = A living will is a written advance directive whereby a person
communicates treatment choices to be implemented if he or she loses
capacity
• Power of Attorney for Healthcare= Identifies a decision-maker when an
individual can no longer make decisions on their own. They must make
decisions based on previously expressed wishes of the patient or in the
patient's best interests. This signed form must be notarized or witnessed.
• The medical POA document is different from the power of attorney form
that authorizes someone to make financial transactions for you.
Medical Orders for Life-Sustaining Treatment (MOLST)
• Autonomy : critical element in providing quality end-of-life care
• (DOH-5003), Medical Orders for Life-Sustaining Treatment
(MOLST)
• Under State law, the MOLST form is the only authorized form in
New York State for documenting both nonhospital DNR and DNI
orders
• MOLST is intended for patients with serious health conditions who:
• Want to avoid or receive any or all life-sustaining treatment;
• Reside in a long-term care facility or require long-term care
services; and/or
• Might die within the next year.
Medical Orders for Life-Sustaining Treatment (MOLST)
• Series of conversations between physician and patient
• Begins with patient if she/he is not cognitively impaired
• If impaired: look to the
• Health Care Proxy
• Surrogate
•
•
•
•
•
•
Court Appointed Guardian
Spouse
Adult children
Parent
Adult Sibling
Close friend or Relative
• Can be used in a variety of health care settings
It’s about how you want to LIVE
•
•
•
•
•
•
•
•
•
•
•
Life-Sustaining Treatment
Antibiotics
Dialysis
Laboratory and other diagnostics
Hospitalization
Artificial Nutrition and Hydration (tube feeding)
Organ Donation
Cardiopulmonary Resuscitation (CPR)
Do-Not-Resuscitate Order (DNR)
Palliative Care
Hospice
It’s about how you want to LIVE
• Learn about your options, choices and decisions
• Implement your advance directive plans
• Voice your decisions
• Engage others to complete their advance directives
CONCLUSIONS
• Older adults face significant challenges to good nutritional status
• It is vital that we are aware of both the common and uncommon
sources and attend to their needs
• Understand that there will come a time when we have to back
away to maintain nutritional status
• Do not be afraid to discuss Advance Directives
• Do not be afraid to talk about death/dying when appropriate
References
• AJ Finestone, G Inderwies . Death and Dying in the US: barriers to the benefits of palliative and hospice care..
Clinical interventions in aging, 2008
• Amarya, Shilpa, Singh, Kalyan, Sabharwal Manisha. Changes during aging and their association with
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• American Geriatric Society (AGS) Feeding tubes in advanced dementia position statement. May 2013
• American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society updated
Beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2012; 60(4):616-31.
• Centers for Medicare and Medicaid Services -42 CFR Part 418, Medicare and Medicaid Programs: Hospice
Conditions of Participation; Final Rule ( Pgs. 32216-32217). http://edocket.access.gpo.gov/2008/pdf/08-1305.pdf
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evidence. JAMA. 1999; 282(14):1365-1370.
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Clinical Gastroenterology and Hepatology. 2007; 5: 1372-1378.
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• Meier DE, Ahronheim JC, Morris J, Baskin‐Lyons S, Morrison RS. High short‐term mortality in hospitalized
patients with advanced dementia: a lack of benefit of tube feeding. Arch Intern Med. 2001;161(4):594‐599.
References
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• The National Hospice and Palliative Care Organization. www.nhpco.org
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