Transcript Nutrition Interventions in the anorexic Geriatric Patient

NUTRITION INTERVENTIONS IN THE
ANOREXIC GERIATRIC PATIENT
By: Nicole Greene
AGENDA
• Defining Geriatrics
• Physiologic Changes of Aging
• Psychological Changes with Aging
• Medical Nutrition Therapy of the Malnourished Geriatric Patient
• Presentation of M.C.
• Critical Comments
• Summary
• Questions
• References
INTRODUCTION
• Aging can’t be prevented
• Malnutrition In the elderly often overlooked
• How does physiologic, mental, and psychological changes affect
nutrition in the elderly population?
• How can an early nutrition intervention improve quality of life?
DEFINING GERIATRICS
• Greek origin
• Geron– elder
• Iatros- healer
• Sub-specialty of internal and
family medicine focused on
prevention and treatment of
diseases and disabilities in the
elderly
• Many countries have accepted the
age of 65 as the definition of
“elderly”
GERIATRIC POPULATION
PHYSIOLOGIC CHANGES ASSOCIATED
WITH AGING
• Different than treating a mid aged adult
• Problems arise from choices made in their
history
• Changes can be summarized into several
categories relating to the organ systems they
compromise
• Every patient unique and may be experiencing
different problems
BONE, MUSCLE, AND JOINT ISSUES IN
THE ELDERLY
Stiff
Joints/Arthritis
Decreased
Bone Density
Muscle Mass
Diminishes
Decreased
Movement
for day-today activities
CARDIOVASCULAR CONDITIONS IN
GERIATRIC PATIENTS
• Atrial Fibrillation
• Hypertension
• Coronary Artery Disease
• Myocardial Infarction
• Congestive Heart Failure
• Valvular Disease
RESPIRATORY CONDITIONS IN THE
ELDERLY
• Decreased elastin
• Decreased vital capacity
• Decrease # of alveoli
• Decrease # of celia
GI SYMPTOMS IN THE ELDERLY
• Decrease in saliva production
• Esophageal dysfunction
• Atrophic gastritis
• Achlorhydria
• Decreased liver metabolism
• Decreased absorption-lactose,
calcium, iron
CHANGES IN THE ELDERLY’S URINARY
SYSTEM
• Vascular blood flow to
the kidneys
decreases
• Nephrons decrease
• Decreased tissue
mass
• Bladder wall become
less elastic
CHANGES IN THE ELDERLY’S NERVOUS
SYSTEM
• Central processing of eye is decreased
• Hearing losses
• Slowing down of thought and memory
• DEMENTIA IS NOT A NORMAL PROCESS OF AGING
CHANGES IN THE ELDERLY’S IMMUNE
SYSTEM
Decline in
number of
antibodies
Shrinking
of Thymus
Gland
Increased Illness and
Infection
PSYCHOLOGICAL ASPECTS OF AGING
• Psychological, biological, environmental, and genetic factors all
contribute to depression
• Depression last longer in the elderly and increases the risk of
death from illness
MALNUTRITION
• Malnutrition Increased morbidity and mortality in elderly
• Lack of protein, energy, and other nutrients causes adverse
effects on tissue form, composition, function, or clinical outcome
• The ADA/A.S.P.E.N. has developed criteria to diagnose
malnutrition in adults
• Serum proteins such as albumin and prealbumin are not
included as defining characteristics of malnutrition
DIAGNOSTIC TOOL TO IDENTIFY MALNUTRITION
Clinical
Charachteri
stic
Malnutrition in the
Malnutrition in the context
context to acute illness or of chronic illness
injury
Malnutrition in the
context of social or
environmental
circumstances
Moderate
Malnutrition
Severe
Malnutrition
Moderate
Malnutrition
Severe
Malnutrition
Moderate
Malnutrition
Severe
Malnutrition
Food and
Nutrient
Intake
< 75% of
est. energy
requirement
for > 7 d ays
≤ 50% of
est. energy
requirement
for ≥ 5 days
< 75% of
est. energy
requirement
for ≥ 1 m
≤ 75% of
est. energy
requirement
for ≥ 1 m
< 75% of
est. energy
requirement
for ≥ 3 m
≤ 50% of
est. energy
requirement
for 1 ≥ m
Interpretatio
n of Weight
Loss
1-2%: 1 wk
5%: 1 m
7.5%: 3 m
>2%: 1 wk
>5%: 1 m
>7.5%: 3 m
5%: 1 m
7.5%: 3 m
10%: 6 m
20%: 1 yr
>5%: 1 m
>7.5%: 3 m
>10%: 6 m
>20%: 1 yr
>5%: 1 m
>7.5%: 3 m
>10%: 6 m
>20%: 1 yr
>5%: 1 m
>7.5%: 3 m
>10%: 6 m
>20%: 1 yr
CAUSES OF MALNUTRITION IN THE
GERIATRIC POPULATION
• Poor appetite
• Chronic illness
• Multiple medications
• Cognitive decline
• Physiologic weakness
• Oral health
• Dysphagia
• Diarrhea or constipation
• Economic hardship
CONSEQUENCES OF MALNUTRITION
• Morbidity and mortality
• Greater risk for infections
• Cachexia
• Failure to thrive
• Delayed wound healing
• Impaired respiratory function
• Muscle weakness
• Depression
ASSESSING THE MALNOURISHED GERIATRIC
PATIENT
• Physical signs
• Muscle wasting
• Temporal wasting
• Poor skin integrity
• Delayed healing
• Subcutaneous fat loss
• Hair loss
ASSESSING THE MALNOURISHED
GERIATRIC PATIENT
• Body Mass Index
BMI
Interpretation
<15
Severely Underweight
<18.4
Underweight
18.5-24.9
Normal
25-29.9
Overweight
30-34.9
Obesity Grade I
35-39.9
Obesity Grade II
>40
Obesity Grade III
23-27
Normal for Elderly (65 and
older)
ASSESSING THE MALNOURISHED
GERIATRIC PATIENT
• Interpretation of % Weight Change
Time
(%) Significant wt
loss
(%) Severe wt loss
1 week
1-2
>2
1 month
5
>5
3 months
7.5
>7.5
6 months
10
>10
Unlimited time
10-20
>20
ASSESSING THE MALNOURISHED
GERIATRIC PATIENT
• FAILURE TO THRIVE
• Syndrome manifested by weight loss greater than 5 percent
of baseline, decreased appetite, poor nutrition, and inactivity
• Four syndromes are prevalent and predictive of adverse
outcomes in patients with FTT:
• Impaired physical function
• Malnutrition
• Depression
• Cognitive impairment
CLINICAL MANIFESTATIONS OF REFEEDING SYNDROME
Hypophosphatemia
Hypokalemia
Hypomagnesemia
Vitamin/Thiamine
Deficiency
Sodium Retention
hypoxia
Nausea/Vomiting
Weakness
Encephalopathy
Fluid overload
Impaired cardiac
function
Paralysis
Muscle Twitching
Lactic Acidosis
Pulmonary Edema
Respiratory failure
Muscle Necrosis
Anorexia
Death
Weakness
Alterations in
myocardial
contraction
Nausea
Vomiting
Diarrhea
Confusion
Electrocardiograph
changes
Electrocardiograph
changes
Restlessness
Cardiac
Arrhythmias
Cardiac
Arrhythmias
Seizures
Sudden Death
Seizures
Coma
weakness
Coma
Death
Respiratory
compromise
Death
Cardiac
Decompensation
ESTIMATING NUTRITIONAL NEEDS IN THE
MALNOURISHED GERIATRIC PATIENT
• Caloric Needs
• Weight based calculations  use actual weight for normal and
underweight individuals
BMI
Interpretation
Kcal/KG
<15
Severely
Underweight
35-40
<18.4
Underweight
30-35
18.5-24.9
Normal
25-30
25-29.9
Overweight
20-25
>30
Obesity
15-20
23-27
Normal for Elderly
22-28
ESTIMATING NUTRITIONAL NEEDS IN
THE MALNOURISHED GERIATRIC
PATIENT
• Caloric Needs
• The Academy suggests a dietary prescription of 130% of the
REE, but should be avoided when the patient is at risk for
refeeding syndrome
• Penn State equation or Ireton Jones for critically ill
ESTIMATING NUTRITIONAL NEEDS IN THE
MALNOURISHED GERIATRIC PATIENT
Protein Needs:
Nourished
Malnourished
0.8-1.0 g/kg
1.2-2.0 g/kg
*Wounds and different disease
states also may increase or
decrease protein needs
ESTIMATING NUTRITIONAL NEEDS FOR
REFEEDING SYNDROME
• Start low and go slow
• Protein should not exceed 1-1.5 gm/kg of normal weight in the
early stages of refeeding
• Calories: 20-25 kcal/kg actual body weight
• If feeding Parenterally: CHO load start with 2 mg/kg/minuteprevents gluconeogenesis and minimizes insulin secretion
• Restrict fluids to avoid edema
• MONITOR LABS: ESPECIALLY PHOSPHORUS, POTASSIUM,
AND MAGNESIUM
METHODS OF FEEDING THE MALNOURISHED
GERIATRIC PATIENT
• Oral Feeding
• Liberalizing the diet
• Add High Calorie/High protein
supplements
• Enteral Nutrition
• Can’t be fed orally or can’t meet needs orally
• Parenteral Nutrition
• Should only be initiated when medically necessary
OTHER INTERVENTIONS
• Possible medication changes
• Remeron
• Appetite stimulants
EVALUATING FEEDING SUCCESS IN THE
MALNOURISHED GERIATRIC PATIENT
• Weight gain (not in fluid)
• Healing wounds
• Nitrogen balance
• A positive nitrogen balance suggest that nutrition intake is
adequate to promote anabolism and preserve lean muscle
mass
• Negative nitrogen balance is when nitrogen excretion
exceeds intake, reflecting muscle deterioration
PRESENTATION OF PATIENT: MC
• 68-year-old widowed Caucasian female
• Transferred from Lions Gate Nursing Home for SOB and
tachycardia
• The patient apparently was not eating at all and is eating less
than 5% of her diet report from Lions Gate Nursing Home
• Weight is only 55 pounds
• The patient was admitted here for psych evaluation for
commitment and inpatient treatment
INITIAL NUTRITION ASSESSMENT (4/18/12)
•
Physician and RN consult, Calorie Count Consult
•
Diagnosis:
•
•
COPD
•
Anorexia
•
Tachycardia
Hx:
•
COPD
• Osteoporosis
•
FTT
• Hypokalemia
• Cachexia
•
Kyphoscoliosis
• Depression
•
Gait Instability
FOOD/NUTRITION HISTORY
• Transferred from Lyons Gate Nursing home
• AAOx3
• PO ~5% per nursing records
• Per H&P: Pt. refuses to eat, hides food, and throws up after meals
• Calorie count initiated today
• Pt. likes ensure and needs soft food
• Noted poor intake x 7 years since husbands death (weight was 126#)
• Per noted record: weight stable at 75# in July 2011
• ? At risk for refeeding
Current Diet Order:
Does not meet needs: pt. needs soft
General Diet +Ensure TID+ Ensure pudding BID, RN to watch pt. eat
meals
LABS:
Lab Value
Normal Range
Current Value
Nutritional Significance
Hemoglobin
12.0-16.0 g/dL
12.3
-
Hematocrit
34.9-44.9%
36.2
-
Sodium
133-145 mmol/L
139
-
Potassium
3.3-5.1 mmol/L
3.4
-
BUN
6-20 mg/dL
6
-
Creatinine
0.40-1.10 mg/dL
<0.30 L
Muscle injury/ decreased
muscle mass, low protein diet
Glucose
80-115 mg/dL
67 L
Missed meals
Calcium
8.8-10.0 mg/dL
8.2 L
Hypoalbuminemia, deficiency,
low Vit. D, malnutrition,
osteoporosis
Phosphorus
2.7-4.5 ml/dL
2.3 L
malnutrition
Magnesium
1.6-2.6 ml/dL
1.6
-
Albumin
3.5-5.3 g/dL
3.1 L
Inflammation, malnutrition
Prealbumin
17-35 mg/dL
10.7 L
Malnutrition, infections
Protein
5.9-8.3 g/dL
5.2 L
Malnutrition, malabsorption
MEDICATIONS
Medication
Use
Protonix
GERD
Prednisone
Inflammation
Heparin
Prevent blood clots
Remeron
Depression/Appetite Stimulant
Oscal/Vit D 500-200
Osteoporosis
K-Dur
Prevent Hypokalemia
Marinol
Appetite Stimulant
Ventolin
COPD
ANTHROPOMETRICS:
Height
5’0
Weight
55 lb or 25 kg
UBW
75 lb or 34 kg (July 2011 or 8
months ago)
% Weight Change
27% in 8 months
IBW
96-125 lb or 44-57 kg
% IBW
57 %
BMI
10.7
PHYSICAL EXAM FINDINGS:
-Multiple Stage I and II Pressure UlcersWound care pending
-Temporal Wasting
-Poor Dentition
-Hair Loss
NUTRITIONAL NEEDS
• Calories
• 625 kcal will increase needs once clear from refeeding
• Based on 25 kg weight
• 25 kcal/kg
• Protein
• 34-51 g
• Based on 34 kg (UBW)
• 1-1.5 g/kg
• Fluid
• ~1290 ml
• Based on 43 kg (IBW)
• 30ml/kg
NUTRITIONAL
DIAGNOSIS
• Suboptimal oral food beverage intake related to
disordered eating as evidenced by weight loss of 26%
over 8 months (severe), anorexia secondary to
depression, BMI: 10.7, 57% of IBW
• Goal: PO intake >50% of each meal/supplements within 3
days (calorie count)
MONITORING AND EVALUATION:
• High acuity
• Weight
• PO intake/ kcal count
• Electrolytes (Na, K, Mg, PO4)
• Skin/Wound Care-pending
• Psych Consult- pending
• Increased needs
NUTRITION INTERVENTIONS
• Nutrition Education:
• Verbal needs for tolerating PO/Increased needs
• Coordination of Other Care During Nutrition Care:
• RN, Physician, and Calorie Count at Bedside
• Recommend:
• Check CRP, Folate, B12, Vit. D
• Start MVI daily
• Change diet to mechanical soft with ground meats
• Pt. would benefit from PEG tube/encourage feeding tube and consider GI
consult for placement
• Monitor Electrolytes- may be at risk for refeeding
• Consider 1:1 for questionable purging
CALORIE COUNT NOTE (4/19/12)
• PO intake poor secondary to eating disorder
• Pt. PO 250 kcal, 7 gm protein
• Minimal PO at breakfast and no PO at dinner
• Pt. reports no appetite, but may be agreeable to PEG
• Pt. complains of early satiety
• Recommendations: As able, GI to F/U with pt. referring
increased anxiety with PEG procedure
UPDATE! (4/19/12)
• Spoke with patient now agreeable for PEG
• Consulted GI
• Will await pulmonary clearance
• Recommend: Once PEG placed, initiate Jevity 1.2 @ 20 ml/hr
and increase by 10 ml q 4 hr until at goal rate of 40 ml/hr x 12 hr
• 480 ml total volume
• 576 kcal
• 27 g Pro
• 687 ml total H20
NUTRITION FOLLOW UP (4/21/12)
• A
•
•
•
•
•
•
•
Pt. ordered clear liquid diet
Calorie count range: 200-500 kcal/day
POD #1 S/P PEG placed
Jevity 1.2 @ 10ml @present (goal is 40 ml x 12hr/day with AF)
Pt. AAOx3 in good spirits
POC: rehab@ D/C
Once PEG feeds tolerated at goal 40mlx12 hr (576 kcal, 27 gm
pro, 687 ml H2O), will progress or change feeds to bolus. No new
lab data
NUTRITION FOLLOW UP CONTINUED (4/21/12)
• D
• Suboptimal EN related to goal not yet reached as evidenced by
EN @ 10 ml/hr (goal is 40 ml/hr x 12 hr)
• Goal: EN to meet estimated needs within 48 hours/ PO feeds for
supplemental
• I
• Closely monitor electrolytes
• Progress PO diet to mechanical soft with ensure BID
• Oral care/ HOB
• Jevity 1.2 @ goal 40 ml/hr x 12 hr/day with AF
NUTRITION FOLLOW UP CONTINUED (4/21/12)
• M/E: High Acuity
• PO intake
• Electrolytes
• EN tolerance
• S/S of aspiration
• Wound Healing
NUTRITION FOLLOW UP (4/24/12)
• A:
• Diet: mechanical soft general diet+ ensure TID+ ensure
pudding BID
• Jevity 1.2 @ goal rate of 40 ml/hr x12 hr via PEG
• Oral PO 0% per RN flow and pt. report
• EN feeds well tolerated
• Would benefit from increased needs with stable electrolytes
NUTRITION FOLLOW UP CONTINUED (4/24/12)
• Estimated needs:
• 875-1000 kcal
• 35-40 kcal/kg
• Based on 25 kg weight
• 66-88 g pro
• 1.5-2.0 g pro
• Based on IBW
• 1275 ml H2O
• Based on IBW
• ~30 ml/kg
NUTRITION FOLLOW UP CONTINUED (4/24/12)
• Additional Medications
• Milk of Magnesia
• Senokot
• Zofran
• Labs
132 L
3.5
93 L
12
33 H
<0.30 L
67 L
NUTRITION FOLLOW UP CONTINUED (4/24/12)
• D:
• Increased nutrient needs related to protein/energy malnutrition as
evidenced by muscle wasting and temporal wasting
• Goal: pt. will meet estimated needs within 24 hours
• I:
• Jevity 1.2 @ 60 ml/hr x 12 hr (7pm-7am) + 2 oz liquid protein via
PEG
• Provides:
• 720 ml total volume
• 864 kcal + 120 (liquid pro) = 984 kcal
• 40 gm pro + 30 gm (liquid pro) = 70 gm pro
• Free H2O with AF: 806 ml
NUTRITION FOLLOW UP CONTINUED (4/24/12)
• M/E:
• Weight
• Electrolytes, prealbumin
• EN tolerance
• Skin/Wound Healing
• Increased needs with weight gain
CRITICAL COMMENTS:
• Improvements
• Diet would have overfed patient
• Should have used actual body weight for protein/fluid
• Nurse couldn’t watch patient eat tray
• Mg and PO4 labs weren’t ordered
• Positives
• Communication between multidisciplinary team
• Gaining patient’s trust
SUMMARY:
• Geriatric population rapidly growing
• Physical and mental changes occur with aging which may lead
to decreased intake
• Multidisciplinary team must be proactive in identifying warning
signs, preventing, and treating malnutrition
• MC example of malnourished geriatric patient
• 3 weeks later, I went to visit MC and she had gained 8.8
pounds. MC was working with PT to walk with a walker, but oral
intake was still minimal
QUESTIONS??
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