Nutrition and Malnutrition in the Elderly

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Nutrition and Malnutrition in the Elderly
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Goals, Objectives, Standards

• Goals
• Appreciate the scope of nutritional assessment
  and intervention in the medical care of the
  elderly
• Objectives
• Practice use of nutrition screens
• Practice implementation of nutritional
  interventions
• Code correctly for evaluation and treatment
• Standards
• Use DETERMINE nutritional screen
• Use Mini Nutritional Assessment
• Compute Body Mass Index
• Compute Ideal Body Weight
• Compute Energy Needs
• Compute Protein Needs

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Case Phase 1 Evaluation of Outpatient

• 82 yr female on a fixed income lives at home
  alone and is dependant upon friends as for
  transportation. She has HTN, CAD, CRF, and OA all
  modestly controlled on HCTZ, ACE1, TNG,
  beta-blocker, and acetaminophen. Her chief
  complaint is having trouble dressing herself
  secondary to L shoulder pain. You note a 10 pound
  weight loss since her last visit six months ago.
• What do you do next?

4
Demographics

• Malnutrition
• Independent 0-6
• Skilled Care 2-27
• Hospital 10-30, up to 75
• Stay is longer with more malnutrition

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MACRONUTRIENTS I

• Water
• 8 x 8 oz/d
• 30ml/kg/d or 1ml/kcal eaten
• Carbohydrates 55-60 total kcal/d
• ½ carbs from whole grains
• Proteins 1 to 1.5 gm/kg/d
• Fats
• Cholesterol
• Fiber 4 gm/d

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Macronutrients II

• Electrolytes
• Na
• K K rich foods , 4700 mg/d blacks
• Mg
• Calcium 1200 mg/d
• Phosphorous 700 mg/d
• Iron 25-40 mg/d

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Micronutrients

• Vitamins, Co-factors
• Minerals
• Trace Elements

• Multivitamin
• Multivitamin
• Multivitamin

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Anthropometrics I

• Clinical
• 10 pound loss in six months or weight
• Relative Risk of Death 2.0
• PPV of malnutrition 0.99
• Minimum Data Set
• Weight loss 5 past month
• Weight loss 10 past six months

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Anthropometrics II

• BMI Body mass index weight (kg) / height (m2)
• Correlated to nutrition status, morbidity,
  mortality
• 18.4 and lower greater risk malnutrition and
  related diseases
• 30 and higher the greater risk for DM, CAD, HTN,
  OA, CA
• National Practice Standard Compute _at_ each
  office visit
• Underweight
• Normal weight 18.5-24.9
• Overweight 25-29.9
• Obesity 30
• Extreme Obesity 40

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BMI Table http//www.nhlbi.nih.gov/guidelines/obes
ity/bmi_tbl2.htm
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BMI NIH Recommendations

• Clinicians should measure BMI and offer obese
  patients intensive counseling and behavioral
  interventions.
• The National Institutes of Health provides a BMI
  calculator at www.nhlbisupport.com/bmi and a
  table at www.nhlbi.nih.gov/guidelines/obesity/bmi_
  tbl.htm.
• The Centers for Disease Control and Prevention
  provides a BMI calculator at www.cdc.gov/nccdphp/d
  npa/bmi/calc-bmi.htm.

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Anthropometrics III Research tools

• Skin fold and mid-arm circumference
• Water Displacement
• Bioelectrical Impedance
• Dual Radiographic Absorptiometry
• CT
• MRI
• Total Body 40K

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Wasting and Cachexia

• Wasting - Severe weight loss and diminished
  nutritional intake
• Semistarvation
• Reduced metabolic demand
• Visceral protein sparing
• Obvious weight loss
• RA, CHF, COPD, HIV, Critical care without
  nutritional support

• Cachexia - Inflammatory cytokine mediated wasting
• Semistarvation overlap
• Increased metabolic demand
• Visceral protein wasting
• ECF incr masks weight loss
• Limited response to antiinflammatory/anabolics
• Nutritional intervention slows semistarvation
  part
• Marasmus, CA, HIV with opp inf, critical care
  without nutritional support, chronic organ failure

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Protein-Energy Undernutriton

• Clinical wasting albumin
• 1/3 hospital
• Big cachexia overlap
• Nutrition support
• Treat underlying disease

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Failure to Thrive

• Not a defined syndrome in the elderly

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DETERMINE Screening Tool

• D isease
• E ating poorly
• T ooth loss, mouth pain
• E conomic hardship
• R educed social contacts
• M ultiple medications
• I nvoluntary weight loss or gain
• N eed for assistance in self-care
• E lderly (age 80)

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DETERMINE Evaluation

• Read the statements below. Circle the number in
  YES column for those that apply to you or
  someone under your care. For each YES answer,
  score the number n the box. Total your nutrition
  score.
• I have an illness or condition that made me
  change the kind and/or amount of food I eat 2
• I eat fewer than 2 meals a day 3
• I eat few fruits or vegetables, or milk
  products 2
• I have 3 or more drinks of beer, liquor, or wine
  almost every day 2
• I have tooth or mouth problems that make it hard
  for me to eat 2
• I dont always have enough money to buy the food
  I need 4
• I eat alone most of the time 1
• I take three or more different prescribed or
  over-the-counter drugs a day 1
• Without wanting to, I have lost or gained 10
  pounds in the last 6 months 2
• I am not always physically able to shop, cook,
  and /or feed myself 2
• Note Scoring 0-2 good, 3-5 moderate
  nutritional risk, 6 or more high nutritional
  risk

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Mini-Nutritional Assessment (MNA)

• Two Part
• 3 min screen
• 8 min diagnostic
• Validated against measurable standards
• Inclusive, Plenary

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MNA Part 1 Skill Session
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MNA Part 2 Skill Session
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MNA Study Results

• Oral supplementation in skilled living elderly
  with MNA 17-23.5 and significantly increased
• calorie intake
• MNA score about 3 points
• Weight about 1.5 kg
• Alzheimers
• Supplementation at 2 kg weight loss stabilizes
  weight loss compared to controls

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Food Pyramids

• MyPyramid.gov
• Culturally distinct
• More flexible

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MyPyramid.gov

• Grains gold
• Vegetables green
• Fruits red
• Oils yellow
• Milk Blue
• Meats Beans Purple
• Discretionary Calories
• Exercise
• 30, 60, 90 rule

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Age Specific Recommendations

• People over age 50.
• Consume vitamin B12 in its crystalline form
  (i.e., fortified foods or supplements).
• Older adults, people with dark skin, and people
  exposed to insufficient ultraviolet band
  radiation (i.e., sunlight).
• Consume extra vitamin D from vitamin D-fortified
  foods and/or supplement

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Nutrient-Nutrient/Drug Interactions

• Numerous
• Ca, Mg, Fe
• Phytins (in fiber)
• Tannins (coffee, tea)

• Bind drugs/nutrients
• Bind drugs/nutrients
• Bind drugs/nutrients

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Drug-Nutrient Interactions I

• Alcohol
• Antacids
• Antibiotics
• Colchicine
• Digoxin
• Diuretics
• Isoniazid
• Levodopa
• Laxatives

• Zn, A, B1, B2, B6, B12, folate
• B12, folate, Fe, kcal
• K
• B12
• Zn, kcal
• Zn, Mg, B6, K, Cu
• B6, niacin
• B6
• Ca, A, B2, B12, D, E, K

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Drug-Nutrient Interaction II

• Lipid Binding Resins
• Metformin
• Mineral Oil
• Phenytoin
• Salicylates
• SSRI
• Theophylline
• Trimethoprim

• A, D, E, K
• B12, kcal
• A, D, E, K
• D, folate
• C, folate
• Kcal
• Kcal
• folate

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Nutrient Treatment of Disease

• Ca and Vit D for osteoporosis
• B6, B12 for homocysteinosis
• Antioxidants CAD, Macular Degeneration
• Vitamin E failed for AD
• Watch for overdosing of vitamins!

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Case Phase 2 Outpatient Treatment

• She responds to in-home physical therapy after a
  steroid injection of her L shoulder. She starts
  to eat breakfast and uses a supplement when her
  appetite is poor. Meals on wheels brings her one
  meal a day. She eats with a friend who cooks
  every Tuesday at lunch. She gains back 7 pounds.

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Case Phase 2 Hospital Evaluation

• Your patient falls and breaks her left hip. She
  survives a L total hip replacement, but develops
  pyelonephritis with bacteremia at the hospital.
  She is delirious. She loses 15 pounds.
• What do you do now?

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Nutrition Requirement Calculations 1

• Estimated Energy Needs by Weight
• 25-30 kcal / kg body weight / day
• Use 120 IBW for obese persons
• Estimated Protein Needs by Weight
• Protein (0.8-1.5) gm / kg body weight / day
• Use IBW for obese persons
• May need to be higher (2.0-3.0) for stressed and
  or very malnourished persons.

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Nutrition Requirement Calculations 2

• Harris-Benedict Basal Estimated Basal Energy
  Expenditure (BEE)
• Male BEE 66 (13.7 x weight in kg) (5 x
  height in cm) (4.7 x age)
• Female BEE 665 (9.6 x weight in kg) (1.8 x
  height in cm) (4.7 x age)
• Multiply by 1.00 (non-stressed) to 1.50
  (stressed)

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Laboratory Evaluation

• Albumin
• Lacks sensitivity and specificity
• May decline very slightly with age
• Negative acute phase reactant
• Prealbumin
• Shorter half-life than albumin
• No more predictive
• Cholesterol
• Indicates underlying serious disease in
  community, hospital and NH patients
• Total Lymphocyte Count

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Tube Feeding

• 3-7 days of 1-2 kcal/ml supplement
• Convert to PEGE for long term use
• 1500-2400 ml per day to achieve water, protein,
  calorie goals
• Start full strength, increase rate
• Measure residuals, convert to bolus feeds
• Supplement enzymes
• Treat diarrhea
• Deal with aspiration

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TPN

• For non-functioning GI tract
• No EMB studies in elders

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Case Phase 2 Hospital Treatment

• After pulling out her NG tube every shift for 24
  hours, she is given TPN through her central line.
  After 48 hours, she is dyspneic, hypoxic, and
  edematous.
• What do you do now?

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Re-feeding Syndrome

• Syndrome of
• hypophosphatemia
• hypomagnesemia
• fluid retention
• about 3 days into re-feeding
• Most pronounced with parenteral nutrition
• Occurs with oral re-feeding as well
• More severe with worse malnutrition
• Frequent subclinical presentation
• Reduce re-feeding rate for three days to treat

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Case Phase 3 Skilled Facility Evaluation

• She recovers from bacteremia, and since she
  cannot tolerate a rehab schedule due to residual
  delirium and weakness is placed in skilled care.
  While there, she does poorly in PT/OT. Has
  restricted diet order for CHF. On narcotics,
  anxiolytics. She is depressed, constipated,
  requires 1-2 person assists for ADLs. She has no
  appetite.

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Anorexia

• Drugs
• Anemia
• Uremia
• Liver Disease
• Dry Mouth
• Pain

• Cancer
• Inflammation
• Psychiatric Illness
• Bowel Disease
• Constipation
• Malnutrition

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Anorexia Appetite Stimulation

• Food Appearance
• Salt
• Sugar
• Social Contact
• Feeding
• Ambience
• Familiarity
• Drugs
• Ghrelin, other hormones

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Anorexia Pharmacologic Support

• Mirtazipine
• probably works
• Cannabis, Cannabinoids, Tetrahydrocannabinol and
  its derivatives
• No therapeutic effect or use in medicine
• Ritalin
• Unsure, probably in depression
• Estrogens/Progestins/Thalidomide
• Probably risk of DVT is too high for routine use
• Corticosteroids
• Especially in cancer, hematologic, neurologic
• Prokinetics
• Cyproheptadine
• Hydrazine sulphate no utility
• Dronabinol
• Antiserotonergic drugs
• Branched-chain amino acids, Eicosapentanoic acid
• Melatonin

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Sarcopenia of the Elderly

• Age related loss of skeletal mass
• Type I fibers spared
• Type II loss of number and size
• Questions
• Sedentary
• Dietary
• Hormonal
• Neurologic
• Sex hormonal

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Case Phase 4

• Recovers

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ICD-9 Codes

• Malnutrition
• 1st degree (mild) 263.1
• 2nd degree (moderate) 263.0
• 3rd degree (severe) (protein calorie) 262
• From neglect 995.84
• Causes problems for NH
• Hypoalbuminemia / Hypoproteinemia 273.8
• Protein Deficiency / Kwashiorkor 260
• Marasmus 261
• Causes problems for NH
• Senile Marsmus 797
• Intestinal Marasmus 569.89
• Lack of Food 994.2
• Nutritional Deficiency, particular, specify 269.9
• Undernourishment/Undernutrition 269.9
• Weight loss (cause unknown) 783.21
• Failure to thrive 783.7
• Causes problems for NH

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Treatment of Malnutrition

• Ease dietary restrictions
• Supplements
• Foods
• Enhanced Milk or Soy based products
• Drugs
• Supportive Therapies

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Summary

• Malnutrition is prevalent in the elderly
• Reproducible assessment is available
• Intervention prevents morbidity and mortality
• Supplements have a role in therapy

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Bibliography

• Cobbs EL, Dithie EH, Murphy JB, eds. Geriatrics
  Review Syllabus A Core Curriculum in Geriatrics
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  Publishing for the American Geriatrics Society
  2002.
• MyPyramid.gov United States Department of
  Agriculture
• Screening for Obesity in Adults. What's New from
  the USPSTF? AHRQ Publication No. 04-IP002,
  December 2003. Agency for Healthcare Research and
  Quality, Rockville, MD. http//www.ahrq.gov/clinic
  /3rduspstf/obesity/obeswh.htm
• http//www.mna-elderly.com/
• Cornali, Cristina, Franzoni, Simone, Frisoni,
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• Visvanathan, Renuka, Macintosh, Caroline,
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  Status of 250 Older Australian Recipients of
  Domiciliary Care Services and Its Association
  with Outcomes at 12 Months.Journal of the
  American Geriatrics Society 51 (7), 1007-1011.doi
  10.1046/j.1365-2389.2003.51317.x
• http//www.nhlbi.nih.gov/guidelines/obesity/bmi_tb
  l2.htm

Journal of the American Geriatrics SocietyVolume
52 Issue 10 Page 1702  - October
2004doi10.1111/j.1532-5415.2004.52464.x
Persson, Margareta D., Brismar, Kerstin E.,
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48
Bibliography

• Hematol Oncol Clin North Am. 2002
  Jun16(3)589-617.Related Articles, Links
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