Transcript Managing Involuntary Weight Loss

Managing Involuntary
Weight Loss in Older
Adults
Jeannine Lawrence, PhD, RD, LD
Division of Human Nutrition
Learning Objectives
• Identify potential causes of involuntary
weight loss in older adults (OAs)
• Explore the potential impact of
involuntary weight loss on physical
function and health outcomes in this
population
• Describe the goals of weight
management in OAs during illness
• Discuss effective, multidisciplinary
strategies for ameliorating involuntary
weight loss in OAs
Definitions & Prevalence
• Unintentional weight loss - loss of body
mass that can occur due to illness or
disease, stress, psychological conditions,
and/or unknown causes
• Weight loss = >3% of body weight or 2 kg
• Clinically relevant – >5% body weight in 6
months
• “Problematic” weight loss
– ≥5% in 1 month
– ≥10% in 6 months or longer
US Omnibus Budget Reconciliation Act of 1987
Definitions & Prevalence (cont.)
• Undernutrition - common in older adults
in Geriatric Med. 2002)
–
–
–
–
5-12% of community-residing older adults
11% of medical outpatients
20% of higher-risk, community-residing
32-50% of hospitalized
• Involuntary weight loss
– Affects 15-20% of older adults
– Contraindicated in the OA
• Including the obese OA
(Clinics
Factors Associated with
Unintentional Weight Loss
M – Medication effects
E – Emotional problems, esp. depression
A – Anorexia nervosa, alcoholism, abuse
L – Late-life paranoia
S – Swallowing disorders
O – Oral factors (e.g. taste, teeth, poorly fitting dentures, caries)
N – No money (poverty)
W – Wandering and other dementia-related behaviors
H – Hyper- and hypothyroidism, hyperparathyroidism, hypoadrenalism
E – Enteric problems
E – Eating problems (e.g. difficulty/inability to feed self)
L – Low-salt, low-cholesterol diets
S – Shopping or social issues (e.g. inability to obtain preferred foods,
isolation, etc)
Morley 1995
Comparison of Causes of
Unintentional Weight Loss in OA
70
60
50
40
OP (n=45)
30
LTC (n=185)
IP (n=154)
20
OP + IP (n=91)
10
0
No identified
cause
Psychiatric
disorder
(including
depression)
Cancer
Benign GI disorder Medication effect
Neurologic
disorder
Other
(hypothyroidism,
poor intake, TB,
food avoidance,
DM, etc)
Huffman 2002
Functional & Health Outcomes
• Physical function
– loss of skeletal muscle mass→ frailty →
decreased mobility
• Health Outcomes
– exacerbate disease
– ↓ immune function
– ↑ morbidity and mortality
Nutrition Screening Tools
• DETERMINE and MNA – extensively validated,
identify at-risk OAs
• Nutrition Screening Initiative (NSI) – 25 national
health and aging organizations
– Developed the Determine Your Nutritional Health
Checklist to highlight warning signs of malnutrition
– Level I – BMI, weight change, eating habits, living
environment, and functional status questions
– Level II – anthropometrics, lab data, clinical exam,
cognitive/mental status evaluation Lipschitz 1992
Nutrition
Screening
Tools (cont.)
•Mini
Nutritional
Assessment
(MNA) – short
and long forms
Step 1 - Assessment
• Anthropometrics (ht, wt, wt change)
– BMI
• height may be inaccurate 2° osteoporosis
• may not be an accurate estimate of lean mass
• 24.0-29.0 may be optimal
Beck 1998
• Medical hx, labs
• Medications and supplement use
• Physical function, physical activity (↓
associated with poorer appetite)
• Psycho/Social – cognition, depression,
social support and interaction
Dietary Intake Assessment in
OAs
• Methods
– Diet records
– 24-hr dietary recall
– FFQ
– Diet history
• Validity of multiple methods are
comparable to younger adults
Special Considerations for Dietary
Intake Assessment in OA
• Memory impaired
– Must assess cognitive abilities
– Avoid - Recall, FFQ
– Add – memory strategies (multiple pass,
product recognition), prior notification of
interview, combining methods
– Caregiver interview beneficial
• Physical limitations – arthritis, eyesight,
etc
– Avoid – self-administered tools
Special Considerations for Dietary
Intake Assessment in OA (cont.)
• Altered dentition
– Probe for specialized food prep
• Chronic illness & specialized diets
– May introduce bias (both + & -)
• Supplement use
Step 2 - Weight Management
• Identify and treat the underlying
cause, then • Dietary goal
1. Stop the weight loss
2. Plan for weight regain (when
appropriate)
•
•
What is reasonable?
+250-500 kcal/day or up to 35 kcal/kg
Interventions to Improve Intake:
Problem- Decreased Volume
• Provide favored foods
– If sweets, choose more nutrient-dense options:
pudding > cookies > hard candies
• Increase snacking, but monitor effect on
meals
• Get creative in masking nutrients to ↑ nutrient
density without ↑ing volume
– Adding protein powders (whey), fiber
supplements, fats/oils to foods and beverages
– Cookbooks available for hiding vegetables in
meals (targeted to parents)
• Diet liberalization – often warranted
Problem: Decreasing Ability to
Prepare Foods
• Keep nonperishable, ready-to-eat
foods available
• Batch cook and freeze complete meals
that can be microwaved (avoid stove
reheating if fatigue or cognition is an
issue)
• Consider enrollment in a community
meal provider service (like Meals on
Wheels)
Problem: Forgetting to Eat or
Drink
• Provide visual cues
– Place foods and beverages in areas where
OA will see them
– Attach notes with reminders to eat in
high-traffic areas
• Offer foods regularly
• Have OA eat with others (in a
controlled setting)
Problem: Loss of appetite
• Due to ↓ taste and smell acuity or medication side
effects
– ↑ spices to enhance flavor
– Serve foods warm to increase aroma
– Cook other foods that smell delicious at mealtimes
• Cookies, bread
• Due to reduction in PA
– ↑ PA
• Due to fatigue
– Maximize on best meal –typically breakfast
– Offer small snacks periodically
– Make every food/beverage count
Problem: Isolation, Depression,
or MCI
• Eat with others
• Easily distracted
– Eat with others so all are performing the
same task
– Serve meals in a quiet, pleasant,
controlled environment
– Use plain plates and tablecloths
Problem: Dental, Chewing, or
Swallowing Issues
• Dental eval
• Swallowing evaluation – may require
medical intervention
– Texture-modified foods
– Thickened liquids
• Dehydration risk
• Supplements – an option, offer >1hour apart
from meals
– consider whole milk with CIB
• Supplemental enteral feeding, or full
enteral feeding
Additional Methods to
Ameliorate Weight Loss
• Engage social and family support
• Increase physical activity
• Address fatigue, sleeping issues
Management During Illness
• Be proactive and aggressive
– Weight loss is a downward spiral
• Consider it a comorbidity (to primary
diagnosis) when developing tx plan
Medications and Supplements
that May Increase Appetite*
Comments
Megace
Remeron
Trazodone
Dexamethasone
Marinol
Metoclopromide
Ornithine oxoglutarate
(OGO)
Do not use – contraindicated for use in
OAs
Anti-anxiety, anti-nausea
Avoid unless for gastroparesis
* All except Megace are non-FDA approved for this
usage in this population
Summary
• Involuntary weight loss -15-20% of older adults
– Contraindicated in the OA, including the
obese
• Interventions require a
multidisciplinary approach
– Begin with identifying the cause
– Assess the patient from medical,
pharmacological, nutrition, and
sociological perspectives
– Address weight management plan from
multiple avenues
Case Study
A 73-year-old woman presents to your
clinic complaining of unintentional
weight loss. She reports having
lost 15 lbs (6.8 kg) over the past
year. She reports that she is eating
three meals per day as usual.
The patient’s past medical history is
notable for:
• Osteoporosis
• Left hip fracture three years
• Osteoarthritis with osteoarthritic
changes in the knees
• Hypothyroidism
• Hypercholesterolemia.
• Radiograph of the chest, CBC,
electrolytes, creatinine, TSH, and
albumin are WNL.
Medications
• levothyroxine
• a statin
• a bisphosphonate
• vitamin D and calcium
• nonsteroidal anti-inflammatory
medications (NSAIDs; prn for knee
pain)
She is an ex-smoker and does not
drink alcohol.
Weight -120 lbs (54.5 kg)
Usual weight - 135 lbs (61.3 kg)
89% of UBW
Body mass index (BMI) - 22.0.
Adapted from Alibhai CMAJ 2005
Case Study (cont.)
On further questioning, the patient admits that:
• Even though she had been eating three meals per day,
she eats less at each meal than previously.
• Her husband of 50 years died suddenly 10 months ago.
– She reports her mood is fine but that she still has not
gotten over his death. She feels lonely and is finding it
difficult to motivate herself to prepare adequate meals for
only one person.
• She also reports experiencing nausea and some
difficulty chewing over the past month.
• You take a closer look in her mouth and notice that her
dentures are loose and that there are a few small ulcers
on her hard palate.
Plan
• In an attempt to address her risk factors, you advise her to
have her dentures adjusted. Suspecting that the NSAIDS may
be contributing to her nausea, you advise her to use
acetaminophen for her knee pains instead. At your
encouragement, she starts attending grief counseling and
becomes involved in social activities, including a supper club,
at her local seniors centre.
• Over the next two months, her appetite improves and she
gains 4#.
• Her weight loss appears to have been the result of multiple
factors, including social isolation, bereavement, chewing
issues, decreased oral intake and possibly the use of NSAIDs.
• Risk factor modification appears to have been successful so
you do not consider further nutritional or pharmacologic
interventions at this time.