By: Nicole Greene

NUTRITION INTERVENTIONS IN THE ANOREXIC GERIATRIC PATIENT

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

Decreased Movement for day-to-

day activities

Decreased Bone

Density

Stiff Joints/Arthri

tisMuscle Mass

Diminishes

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

Increased Illness and Infection

Shrinking of Thymus

Gland

Decline in number of antibodies

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

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

Interpretation of Weight Loss

1-2%: 1 wk5%: 1 m7.5%: 3 m

>2%: 1 wk>5%: 1 m>7.5%: 3 m

5%: 1 m7.5%: 3 m10%: 6 m20%: 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

Clinical Charachteristic

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

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

NauseaVomitingDiarrhea

Cardiac Decompensation

Confusion Electrocardiograph changes

Electrocardiograph changes

Restlessness Cardiac Arrhythmias

Cardiac Arrhythmias

Seizures Sudden Death Seizures

Coma weakness Coma

Death Respiratory compromise

Death

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

• FTT

• Cachexia

• Kyphoscoliosis

• Osteoporosis

• Hypokalemia

• 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:General Diet +Ensure TID+ Ensure pudding BID, RN to watch pt. eat meals

Does not meet needs: pt. needs soft

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 GERDPrednisone InflammationHeparin Prevent blood clotsRemeron Depression/Appetite StimulantOscal/Vit D 500-200 OsteoporosisK-Dur Prevent HypokalemiaMarinol 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 Ulcers- Wound 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

67 L132 L

3.5

93 L

33 H

12

<0.30 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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