NUTRITION INTERVENTIONS IN THE ANOREXIC GERIATRIC PATIENT By

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 Decrease d Bone Density Stiff Joints/Art hritis Decreased Movement for day-today activities Muscle Mass Diminish es

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 antibodie s Shrinkin g 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

MALNUTRITION Clinical Characht eristic Malnutrition in the context to acute illness or injury Malnutrition in the context of chronic illness Malnutrition in the context of social or environmental circumstances Moderate Severe Malnutritio Malnutritio n n n Food and Nutrient Intake < 75% of est. energy requireme nt for > 7 d ays ≤ 50% of est. energy requireme nt for ≥ 5 days < 75% of est. energy requireme nt for ≥ 1 m ≤ 75% of est. energy requireme nt for ≥ 1 m < 75% of est. energy requireme nt for ≥ 3 m ≤ 50% of est. energy requireme nt for 1 ≥ m Interpretat ion 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

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

SYNDROME Hypophosphate mia Hypokalemia Hypomagnesemi a hypoxia Nausea/Vomitin Weakness g Vitamin/Thiamin e Deficiency Sodium Retention Encephalopathy Fluid overload Impaired Paralysis cardiac function Muscle Twitching Lactic Acidosis Respiratory failure Muscle Necrosis Anorexia Death Weakness Alterations in myocardial contraction Nausea Vomiting Diarrhea Confusion Electrocardiogr aph changes Restlessness Cardiac Arrhythmias Seizures Sudden Death Seizures Pulmonary Edema Cardiac Decompensatio n

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 0. 8 -1. 0 g/kg Malnourished 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/minute- prevents 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 • Depression • Kyphoscoliosis • Gait Instability

FOOD/NUTRITION HISTORY • Transferred from Lyons Gate Nursing home • AAOx 3 • 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 Does not meet needs: pt. needs soft Current Diet Order: • ? At risk for refeeding 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/d. L 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/d. L 6 - Creatinine 0. 40 -1. 10 mg/d. L <0. 30 L Muscle injury/ decreased muscle mass, low protein diet Glucose 80 -115 mg/d. L 67 L Missed meals Calcium 8. 8 -10. 0 mg/d. L 8. 2 L Hypoalbuminemia, deficiency, low Vit. D, malnutrition, osteoporosis Phosphorus 2. 7 -4. 5 ml/d. L 2. 3 L malnutrition Magnesium 1. 6 -2. 6 ml/d. L 1. 6 - Albumin 3. 5 -5. 3 g/d. L 3. 1 L Inflammation, malnutrition

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 -Multiple Stage I and II Pressure Ulcers- Wound care pending -Temporal Wasting -Poor Dentition -Hair Loss PHYSICAL EXAM FINDINGS:

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) • 30 ml/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, PO 4) • 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, B 12, 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 H 20

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 @ 10 ml @present (goal is 40 ml x 12 hr/day with AF) • Pt. AAOx 3 in good spirits • POC: rehab@ D/C • Once PEG feeds tolerated at goal 40 mlx 12 hr (576 kcal, 27 gm pro, 687 ml H 2 O), 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 x 12 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 H 2 O • 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 (7 pm-7 am) + 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 H 2 O 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 PO 4 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? ?

REFERENCES • "Geriatrics Definition - Medical Dictionary Definitions of Popular Medical Terms Easily Defined on Med. Terms. " Medterms. Medicine. Net, Inc, 14 June 2012. Web. 22 July 2012. <http: //www. medterms. com/script/main/art. asp? articlekey=18385>. • United States. U. S. Department of Health and Human Services. Administration of Aging. U. S. Census Bureau. By Donald G. Fowles and Saadia Greenberg. N. p. , 2011. Web. 15 May 2012. <http: //www. aoa. gov/aoaroot/aging_statistics/Profile/ 2011/docs/2011 profile. pdf>. • Dugdale, III, MD, David C. "Aging Changes in the Bones - Muscles - Joints. "Medline Plus. A. D. A. M. , Inc. , 28 June 2012. Web. 22 July 2012. <http: //www. nlm. nih. gov/ medlineplus/ency/article/004015. htm>. • Schwartz, M. D. , Janice B. "Cardiovascular Function and Disease in the Elderly. ” Galter Health Sciences Library, 9 June 1999. Web. 5 June 2012. <http: // www. galter. northwestern. edu/geriatrics/chapters/ cardiovascular_function_disease. cfm>.

REFERENCES • Schriber, MD, FCCP, Andrew. "Aging Changes in the Lungs. " Medline Plus. A. D. A. M. , Inc. , 29 Nov. 2010. Web. 6 June 2012. <http: //www. nlm. nih. gov/ medlineplus/ency/article/004011. htm>. • Boss MD, Gerry R. , and EDWIN J. SEEGMILLER, MD, . "Age-Related Physiological Changes and Their Clinical Significance. " The Western Journal of Medicine 6 th ser. 135 (1981): 434 -40. Print. • Woudstra, Trudy, and Alan B. R. Thomson. "Nutrient Absorption and Intestinal Adaptation with Ageing. " Best Practice & Research Clinical Gastroenterology 16. 1 (2002): 1 -15. Print. • "Urinary System. " American Academy of Health and Fitness, 2011. Web. 22 July 2012. <http: //www. aahf. info/sec_exercise/section/ urinary. htm>.

REFERENCES • Dugdale, III, MD, David C. "Aging Changes in the Nervous System. " Medline Plus. A. D. A. M. , Inc. , 17 Nov. 2010. Web. 12 June 2012. <http: //www. nlm. nih. gov/ medlineplus/ency/article/004023. htm>. • Besdine, MD, FACp, AGSF, Richard W. , and Difu Wu. "Aging of the Human Nervous System: What Do We Know? " Medicine and Health 91. 5 (2008): 129 -31. Print. • Duckworth, M. D. , Ken. "Depression in Older Persons Fact Sheet. " National Alliance of Mental Illness. NAMI, Oct. 2009. Web. 22 July 2012. <http: //www. nami. org/ Template. cfm? Section=By_Illness>. • "Malnutrition in the Elderly. " Malnutrition in the Elderly. Nestle Healthcare Nutrition, 2012. Web. 23 July 2012. <http: //www. nestlenutrition. co. uk/healthcare/gb/ health_concerns/elderly_malnutrition/Pages/memalnutrition. aspx>.

REFERENCES • Wells, Jennie L. , and Andrea C. Dumbrell. "Nutrition and Aging: Assessment and Treatment of Compromised Nutritional Status in Frail Elderly Patients. " Clinical Interventions in Aging 1. 1 (2006): 67 -79. Print. • Skipper Ph. D, RD, FADA, Annalynn. "Malnutrition Criteria. "Http: // www. nutritioncaremanual. org/. Academy of Nutrition and Dietetics, 2012. Web. 23 July 2012. <http: //www. nutritioncaremanual. org/content. cfm? ncm_content_id=111002>. • Hickson, M. "Malnutrition and Ageing. " Postgraduate Medical Journal 82. 963 (2006): 2 -8. Print. • Logemann, Ph. D, Jeri, Charles Stewart, M. D, Jane Hurd, MPA, Diane Aschman, MS, and Nancy Matthews, MA. "Diagnosis and Management of Dysphagia in Seniors. " Http: //americandysphagianetwork. org/. N. p. , July 2011. Web. 23 July 2012. <http: //americandysphagianetwork. org/physician_education_course>.

REFERENCES • Mc. Guire, Michelle, and Kathy A. Beerman. Nutritional Sciences: From Fundamentals to Food. Belmont, CA: Wadsworth Cengage Learning, 2011. Print. • Mueller, C. Compher, and D. M. Ellen. "A. S. P. E. N. Clinical Guidelines: Nutrition Screening, Assessment, and Intervention in Adults. " Journal of Parenteral and Enteral Nutrition 35. 1 (2011): 16 -24. Print. • Kraft, M. D. , I. F. Btaiche, and G. S. Sacks. "Review of the Refeeding Syndrome. "Nutrition in Clinical Practice 20. 6 (2005): 625 -33. Print. • Queensland Health NEMO Nutrition Support Group. "Estimating Energy & Protein Requirements for Adult Clinical Conditions. " Health. qld. gov. Queensland Health, Mar. 2011. Web. 23 July 2012. <http: //www. health. qld. gov. au/nutrition/resources/ est_rqts. pdf>. • Huffman M. D. , Grace B. "Evaluating and Treating Unintentional Weight Loss in the Elderly. " American Family Physician 4 th ser. 15. 65 (2002): 640 -51. Print.