nutrition and malnutrition 112806

8/4/2019 Nutrition and Malnutrition 112806

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Nutrition and Malnutrition inthe 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 homealone and is dependant upon friends as fortransportation. She has HTN, CAD, CRF, and

OA all modestly controlled on HCTZ, ACE1,TNG, beta-blocker, and acetaminophen. Herchief complaint is having trouble dressingherself secondary to L shoulder pain. You

note a 10 pound weight loss since her lastvisit six months ago.

What do you do next?


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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 carbs from whole grains

Proteins 1 to 1.5 gm/kg/d

Fats 4 gm/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 < 100 lbs

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 @ each office visit

Underweight = 30

Extreme Obesity >= 40


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BMI Table http://www.nhlbi.nih.gov/guidelines/obesity/bmi_tbl2.htmBMI 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35

Height Body Weight (pounds)

58 91 96 100 105 110 115 119 124 129 134 138 143 148 153 158 162 167

59 94 99 104 109 114 119 124 128 133 138 143 148 153 158 163 168 173

60 97 102 107 112 118 123 128 133 138 143 148 153 158 163 168 174 179

61 100 106 111 116 122 127 132 137 143 148 153 158 164 169 174 180 185

62 104 109 115 120 126 131 136 142 147 153 158 164 169 175 180 186 191

63 107 113 118 124 130 135 141 146 152 158 163 169 175 180 186 191 197

64 110 116 122 128 134 140 145 151 157 163 169 174 180 186 192 197 204

65 114 120 126 132 138 144 150 156 162 168 174 180 186 192 198 204 210

66 118 124 130 136 142 148 155 161 167 173 179 186 192 198 204 210 216

67 121 127 134 140 146 153 159 166 172 178 185 191 198 204 211 217 223

68 125 131 138 144 151 158 164 171 177 184 190 197 203 210 216 223 230

69 128 135 142 149 155 162 169 176 182 189 196 203 209 216 223 230 236

70 132 139 146 153 160 167 174 181 188 195 202 209 216 222 229 236 243

71 136 143 150 157 165 172 179 186 193 200 208 215 222 229 236 243 250

72 140 147 154 162 169 177 184 191 199 206 213 221 228 235 242 250 258

73 144 151 159 166 174 182 189 197 204 212 219 227 235 242 250 257 265

74 148 155 163 171 179 186 194 202 210 218 225 233 241 249 256 264 272

75 152 160 168 176 184 192 200 208 216 224 232 240 248 256 264 272 279

76 156 164 172 180 189 197 205 213 221 230 238 246 254 263 271 279 287


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BMI: NIH Recommendations

Clinicians should measure BMI and offer obesepatients intensive counseling and behavioralinterventions.

The National Institutes of Health provides a BMIcalculator at www.nhlbisupport.com/bmi and a tableat www.nhlbi.nih.gov/guidelines/obesity/bmi_tbl.htm.

The Centers for Disease Control and Prevention

provides a BMI calculator atwww.cdc.gov/nccdphp/dnpa/bmi/calc-bmi.htm.
http://www.nhlbisupport.com/bmihttp://www.nhlbi.nih.gov/guidelines/obesity/bmi_tbl.htmhttp://www.cdc.gov/nccdphp/dnpa/bmi/calc-bmi.htmhttp://www.cdc.gov/nccdphp/dnpa/bmi/calc-bmi.htmhttp://www.cdc.gov/nccdphp/dnpa/bmi/calc-bmi.htmhttp://www.cdc.gov/nccdphp/dnpa/bmi/calc-bmi.htmhttp://www.nhlbi.nih.gov/guidelines/obesity/bmi_tbl.htmhttp://www.nhlbisupport.com/bmi


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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 diminishednutritional intake

Semistarvation

Reduced metabolic demand

Visceral protein sparing

Obvious weight loss

RA, CHF, COPD, HIV, Criticalcare without nutritional support

Cachexia - Inflammatory

cytokine mediated wasting

Semistarvation overlap

Increased metabolic demand

Visceral protein wasting

ECF incr masks weight loss

Limited response toantiinflammatory/anabolics

Nutritional intervention slowssemistarvation part

Marasmus, CA, HIV with oppinf, critical care withoutnutritional support, chronicorgan failure


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Protein-Energy Undernutriton

Clinical wasting + albumin < 3.5 gm/dl

> 1/3 hospital

< 1/3 NH

< 10% independent

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 Your Nutritional Health Checklist. Nutrtion Screeining Initiative, a project of the American Academy of Family Physicians, the American Dietetic Association, and theNational Council on Aging, Inc., and funded in part by Ross Products Division,

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 elderlywith MNA 17-23.5 and < 17 with 1 can (400kcal) 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

< 200 to 300 kcal

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, andpeople exposed to insufficient ultraviolet bandradiation (i.e., sunlight).

Consume extra vitamin D from vitamin D-fortifiedfoods 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 2Outpatient Treatment

She responds to in-home physical therapyafter a steroid injection of her L shoulder. Shestarts to eat breakfast and uses a supplement

when her appetite is poor. Meals on wheelsbrings her one meal a day. She eats with afriend 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. Shesurvives a L total hip replacement, butdevelops pyelonephritis with bacteremia at

the hospital. She is delirious. She loses 15pounds.

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 andor very malnourished persons.


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Nutrition Requirement Calculations 2

Harris-Benedict Basal Estimated BasalEnergy 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 < 3.8 g/dl Lacks sensitivity and specificity

May decline very slightly with age

Negative acute phase reactant

Prealbumin Shorter half-life than albumin

No more predictive

Cholesterol < 160 mg/ml Indicates underlying serious disease in community, hospital

and NH patients

Total Lymphocyte Count < 2000 cells/microliter


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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 for24 hours, she is given TPN through hercentral 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 shecannot tolerate a rehab schedule due toresidual delirium and weakness is placed in

skilled care. While there, she does poorly inPT/OT. Has restricted diet order for CHF. Onnarcotics, anxiolytics. She is depressed,constipated, requires 1-2 person assists forADLs. 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 Medicine. 5thed. Malden, MA: Blackwell 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, December2003. 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, Giovanni B. & Trabucchi, Marco (2005)

ANOREXIA AS AN INDEPENDENT PREDICTOR OF MORTALITY.Journal of the American Geriatrics Society53 (2), 354-355.doi: 10.1111/j.1532-5415.2005.53126_4.x

Visvanathan, Renuka, Macintosh, Caroline, Callary, Mandy, Penhall, Robert, Horowitz, Michael & Chapman, Ian (2003)The Nutritional Status of 250 Older Australian Recipients of Domiciliary Care Services and Its Association with Outcomes at 12 Months.Journal of the American Geriatrics Society51 (7), 1007-1011.doi: 10.1046/j.1365-2389.2003.51317.x

http://www.nhlbi.nih.gov/guidelines/obesity/bmi_tbl2.htm

Persson, Margareta D., Brismar, Kerstin E., Katzarski, Krassimir S., Nordenstrm, Jrgen & Cederholm, Tommy E. (2002) Nutritional Status UsingMini Nutritional Assessment and Subjective Global Assessment Predict Mortality in Geriatric Patients. Journal of the American GeriatricsSociety50 (12), 1996-2002.doi: 10.1046/j.1532-5415.2002.50611.x

Journal of the American Geriatrics SocietyVolume 52 Issue 10 Page 1702 - October 2004doi:10.1111/j.1532-5415.2004.52464.x
http://www.ahrq.gov/clinic/3rduspstf/obesity/obeswh.htmhttp://www.nhlbi.nih.gov/guidelines/obesity/bmi_tbl2.htmhttp://www.nhlbi.nih.gov/guidelines/obesity/bmi_tbl2.htmhttp://www.ahrq.gov/clinic/3rduspstf/obesity/obeswh.htm


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Bibliography

Hematol Oncol Clin North Am. 2002 Jun;16(3):589-617.Related Articles, Links

Update on anorexia and cachexia.

Strasser F, Bruera ED.

Department of Palliative Care and Rehabilitation Medicine, MD Anderson Cancer Center, 1515 Holcombe Boulevard, Box 0008, Houston, TX 77030, USA

Cancer Surv. 1994;21:99-115.Anorexia and cachexia in advanced cancer patients.

Vigano A, Watanabe S, Bruera E.

Palliative Care Program, Edmonton General Hospital, Canada.CA Cancer J Clin. 2002 Mar-Apr;52(2):72-91.

Cancer anorexia-cachexia syndrome: current issues in research and management.

Inui A.

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