UNDERNUTRITION AND WEIGHT LOSS IN THE ELDERLY

NAUSHIRA PANDYA M.D.,C.M.D.Chair and Associate ProfessorDepartment of Geriatrics Director, Geriatric Education Center, NSU COM

CECILIA ROKUSEK Ed.D., R.D.Professor of Family Medicine and Public HealthExecutive Director, Geriatric Education Center, NSU COM

The scope of the problemMode of living Prevalence(%) References

Free-living 5 Dept of Health and Social Sec, UK

7 Dept of Health and Social Sec, UK

5 Blondel-Cynober et al.2 Lowink et al.1-4 Cederholm et al.

Hospital 39 Cederholm et al.59 Rapin et al.50 Alix.22 Volkert et al.

Nursing home 30-60 Rudman et al.10-85 Kerstetter et al.

Change in food intake over the life span-NHANES III

0

500

1000

1500

2000

2500

3000

3500

20-29 30-39 40-49 50-59 60-69 70-79 >80

Age(y)

(Kca

l)

45

46

47

48

49

50

51

52

(% o

f ene

rgy)

Kcal MenKcal WomenCarbs

NHANES 111 DATA

4% of persons between 60-69 yr were unable to prepare their meals or walk around23% of persons over 80 yr were unable to prepare their meals and 17% were unable to walkGFR < 30ml/min/1.72m2 major risk factor for malnutrition in older adults30-40% of patients on dialysis were malnourished

Marwick C. JAMA 1997;227

Normal aging changes, physical, psychological and social precipitants

AnorexiaWeight loss

Malnutrition

Depression

Cognitive dysfunction

Social withdrawal

Isolation Giving up DEATH Egbert

Barriers to adequate nutritional management of older patients by physicians

Inadequate training in recognizing protein calorie undernutritionUnawareness that protein calorie undernutrition may be the presenting feature of many treatable diseases in the elderlyUnawareness of currently available treatment options

Morley

Conditions associated with protein-energy undernutrition in the elderly

Immune deficiency, increased infection, pneumoniaPressure ulcersPoor wound healingAnemiaFallsCognitive deficits, increased deliriumOsteopenia, hip fracturesAltered drug metabolismSarcopenia, weakness, fatigueOrthostatic hypotension and dehydrationNon-thyroidal illnessDecreased maximal breathing capacityDecreased cardiac output

Predictors of nutritional disorders and disability

Katz ADL index scoreSerum albumin levelPatient’s current weight as percentage of usual weightNumber of prescribed medications takenPresence of renal disease (BUN level > 30)Individual’s incomePresence of one or more decubiti (grade II or higher)DysphagiaMid-arm muscle circumference

Sullivan DH

Nutrition and immunity in the elderly

Infections are more common in the undernourished - especially pulmonaryCell-mediated immunity and delayed hypersensitivity declinesTotal lymphocyte count ↓ (< 800/mm3 reflects undernutrition)T cell proliferation ↓B lymphocyte proliferation Cytokine release ↓ (IL2 and IL1) - fever often absent, and inflammatory syndromes have prolonged evolution periods

CD4:CD8 ratio in undernourished patients who are HIV -

Micronutrient supplementation has been showed to restore T cell deficiency (zinc-thymulin, Vit E -?antioxidant)

Usual aging is associated with decrease in skeletal and visceral lean body mass (LBM), bone density, total body water, and increase in total fat

SARCOPENIA wasting of skeletal muscleLBM declines 19% in men and 12% in women (25-75y)Due to aging, inactivity, malnutrition, catabolic diseases (CHF, COPD, cancer, hyperthyroidism)

CACHEXIA is loss of both muscle and fatNot physiologicOccurs in malignancies and HIV disease Systemic inflammatory response

Outcomes of Severe Weight Loss in Older Persons

Increased hospitalizationIncreased length of hospital stayIncreased hospital costsDelayed recovery from surgeryIncreased mortality (weight loss in 6 mths in NH pts associated with 2 fold increase in likelihood of death- Yamashita et al. 2002)

Increased NH placement in older women (BMI < 21.4 Kg/m2 )

The assessment

Case 1A 73 yr old woman is noted to have a 10 lb involuntary weight loss at her annual physicalFood just does not appeal to her and she can’t be bothered with meals; she lives aloneShe has HTN, osteoarthritis, glaucoma, and T2 diabetesMedications: captopril, metformin, naproxenExam: unkempt, apathetic, R knee effusion

What further questions would you ask?

What would you look for in the physical exam?

Important points in the history

Anorexia?Early satiety?Nausea?Change in bowel habits?Fatigue or apathy?Memory loss?Depression?Food availability? Poverty?Social history

Physical signs of Undernutrition

Loss of subcutaneous fat- interossei and palmar creases- loss of fullness in arms, chest wall- squared-off appearance of shoulders

Muscle wasting (sarcopenia)- loss of tone and bulk in quadriceps, deltoids- reduced strength

Edema of ankles, sacrum, and even ascites- absence of weight loss misleading

Dysphoria, decreased cognitionPoor wound healing, pressure ulcers

Parameters Used in Identifying Undernutrition

Body weight loss (>5% in 30 days or 10% in 180 days)Body mass index < 19 kg/m2 (may be spuriously elevated)

Severe if BMI < 16Dietary food intake of less than 75% of meals for 3 daysSerum albumin value of less than 3.5 or 3.0 g/dl (decreases by 0.8 per decade after age 60) Influenced by

posture, CHF, dialysis, cytokines, dialysis, nephrosis, paraproteinemias

Serum cholesterol value of less than 160 mg/dl (occurs late, limited use for screening)

Associated with hospitalizations, LOS, complications, mortality

Screening and Assessments ToolsSCALES - outpatient screening toolDETERMINE - a low specificity tool, increases public awareness, and easily performed by the patient

- developed by the Nutrition Screening Initiative (AAFP, Am Diet.Assoc, Nat Council of the Aging)- Level I Screen separates those who need evaluation and intervention from those who need other medical and community services

- Level II Screen by physician or other primary provider (includes anthropometrics, labs, social and functional testing

MNA - Mini Nutritional Assessment. Malnutrition Inflammation Score (dialysis patients)

SCALES Protocol for evaluating risk of malnutrition in the elderly (scores > 3 indicates patient at clear risk) Morley 1991

Item evaluated Criterion for 1 point Criterion for 2 points

Sadness GDS 10-14 > 15

Cholesterol < 160 mg/dl --

Albumin 3.5 - 4.0 g/dl < 3.5 g/dl

Loss of weight (MAC 1 month)

1 kg (or ¼” in MAC in 6 months)

3 kg (or 1/2”)

Eating problems assistance

Patient needs --

Shopping and food prep problems

Patient needs assistance

--

Why does caloric intake decrease in the elderly?

ALTERATIONS IN THE HEDONIC QUALITIES OF FOOD WITH AGING

Food enjoyment depends on taste, odor, temperature, texture, masticatory sounds, all of which are alteredSmell declines progressively; hence monotonous diets

Alzheimer’s, Parkinsonism, laryngectomy, B12 deficiency, hypothyroidism, RF, cirrhosis, diltiazem, streptomycin

Reduction in sensory-specific satietyIncrease in taste thresholds; sweet least affected modality; flavor enhanced foods better consumedDifficulty recognizing taste mixturesSocial isolation

Anorexia of aging- Physiological reduction in food intake with advanced age

Food intake is lower in healthy older persons, especially of fat rather than carbohydrates

BMR due to loss of muscle

ImmobilityGreater satiation after a standard meal than younger peopleReduced fundic nitric oxide leads to a decrease in adaptive relaxation and earlier satiation ( by leptin, by NPY)

Opiod feeding drive (for fats) is less efficient Refeeding can reset appetite

Copyright ©2006 BMJ Publishing Group Ltd.

Hoffer, L J. BMJ 2006;333:1214-1215

Elderly demented patients often eat enough for their diminished energy requirements

Some postulatedfactors involved in the pathogenesis of physiologic anorexia

Taste and smell

CENTRAL NERVOUS SYSTEM

DynorphinNeuropeptide YCART

ANOREXIA

WEIGHT LOSS

CYTOKINESTNF αInterleukin-1Interleukin-6

STOMACHadaptive relaxn

Antral stretch

DUODENUMcholecysto-

kinin

OVARIESestrogen

ADIPOCYTESleptin

TESTIStestosterone

muscle mass

Neurotransmitters and Hormones Involved in the Control of Food Intake ( changes with aging)

Stimulate Inhibit

Peripheral motilinghrelin

CholecystokininGlucagon-like peptide 1

Amylin

Leptin (males only)cytokines

Hormones Thyroid CortisolTestosterone Progestagens

Estrogen (females only)

Central Dynorphin Dopamineneuropeptide Y Norepi

orexinA HistamineMelanin-conc H NO

CRHSerotoninIsatinDopamine

CART

Pathophysiology of protein-energy malnutrition.

Stress, InfectionBurns, Trauma

Inc macrophage proliferationInc release of IL1, TNFColony stim factorGamma interferon

Inc ESRLeukocytosisAnorexiaProtein catabolismWeight loss

Increase inGlucocorticoidsMineralocorticoidsADHDecreased IGF1

GluconeogenesisProtein catabolismLipolysisFluid, electrolyte shifts

Protein Energy MalnutritionHypoalbuminemiaLiver dysfunctionDecreased host defensesInc requirement for Cals + protein

“Meals on Wheels”: causes of weight loss

M: medications (dig, theophylline, fluoxetine)E: emotional (depression)A: alcohol, anorexia tardive, or elder abuseL: late life paranoiaS: swallowing problems (dysphagia, candidiasis, webs)

O: oral or dental problems (xerostomia)N: nosocomial infections (TB, C.Diff, H Pylori)

W: wandering, dementia problemsH: hyperthyroidism, hypercalcemia, hypoadrenalismE: enteric problems (gluten entropathy, pancreatic insufficiency)E: eating problemsL: low salt, low fat diets (ADA and other therapeutic diets)S: shopping and food preparation problems Morley

Causes of weight loss - MEDICALDysgeusia (antibiotics, captopril, tegretol, allopurinol, L dopa, lithium, baclofen, antihistamines, Vit A, zinc deficiency)Anorexia (Addison’s disease, dyspepsia*,H. Pylori infection, hypercalcemia)Oral and swallowing problems, dry mouth, poorly fitting dentures, web stricture, esophageal candidiasisMalabsorption (Celiac disease, intestinal ischemia)Increased metabolism (hyperthyroidism, pheochromocytoma)Metabolic (diabetes, hepatic, renal, cardiac failure)Chronic infections, TBMixed causes (cancer*, Parkinsonism, COPD, cardiac cachexia)

Causes of weight loss - SOCIALPoverty, fixed incomeFunctional impairment limiting ADL’S, dependancySocial IsolationElder abuse, caregiver fatiguePoor nutritional knowledgeFinicky eatersAlcoholInstitutional factors- inadequate assistanceEthnic food preferencesMonotony of institutionalized food

Causes of weight loss -PSYCHOLOGIC

DementiaDepression*BereavementAlcoholismLate-life mania or paranoiaAnorexia tardive or nervosaSociopathy (loss of locus of control)Excessive burden of lifePhobias (cholesterol or choking)Globus hystericus

Drug Therapy That May Contribute to Nutritional Disorders

Cardiac glycosides (digoxin)DiureticsAnti-inflammatory drugsAntacids (overuse)Psychotropic drugsAntidepressants (SSRI’s)Antineoplastic drugsAnticonvulsantsPhenothiazinesOral hypoglycemicsAnti-parkinsonianAnticholinergic

Alibhai, CMAJ. 2005 March

So What is Frailty?

A physiologic state of increase vulnerability to stressors that results from decreased physiologic reserves and even dysregulation, of multiple physiologic systemsEvidence indicates that Frailty may be a result of alterations in metabolic activity, that then leads to derangement of normal physiology

Cytokine over expressionHormonal imbalances

Frailty vs. Disability vs. Co morbidity

Fried, LP, et al. Journal of Gerontology 2001 M146 – M156

Consequences of FrailtyDisability

Difficulty with Activities of Daily living

Dependency

Falls

Need for Long – Term Care

Mortality

Phenotype of FrailtySHRINKING

Unintentional weight lossSarcopenia

WEAKNESSPOOR ENDURANCE & ENERGYSLOWNESSLOW ACTIVITY

Fried, LP, et al. Journal of Gerontology 2001 M146 – M156

FRAILTY: 3 or more criteria

PREFRAILTY: 1 or 2 criteria

Frailty Syndrome Criteria

WEAKNESSGrip strength in the lowest 20% at baseline; adjust for gender and BMIMEN Cutoff for Grip Strength

(Kg) criterion for frailtyBMI </= 24BMI 24.1 – 26BMI 26.1 – 28BMI > 28

<29<30<30<32

WOMEN Cutoff for Grip Strength (Kg) criterion for frailty

BMI </= 23BMI 23.1 – 26BMI 26.1 – 29BMI > 29

<17<17.3<18<21

Aging & Frailty

Revised schematic of homeostenosis: The older person employs or consumes physiologic reserves just to maintain homeostasis, and therefore there are fewer reserves available for meeting new challenges

Copyright © 2003 Spring-Verlag New York, Inc. All rights reserved.

Cycle of Frailty

Cytokine Over ExpressionIL-6, IL-1, TNF-a, IL-2, Hsp70

Sarcopenia

Osteoporosis or osteopenia

anemia

Cognitive decline

atherosclerosis

Impairments in Function, mobility, and/or endurance

PAD, CAD, Cerebrovascular disease

Dementia Fractures Falls

Falls, Heart failure…

FRAILTY

Cytokines & FrailtyInterleukin -6 (IL-6), TNF-alpha, Heat Shock protein 70:

Found to be elevated in older adults who complain of fatigue and found to have poor mobility and poor muscle endurance

Bautmans et al. JAGS. 56:3, pgs 389-396

IL-6 found to be elevated in older people with cachexia

Hubbard et al. JAGS. 56:2, pgs 279-284

That subclinical anemia may be a related to chronic inflammatory state marked by serum IL-6 elevation

Leng et al. JAGS. 50:7, pgs 1268-1271

Hormones & FrailtyHormone Deficient states may lead to the

following

Growth Hormone, IGF-1 Sarcopenia, Osteoporosis

Testosterone Cognitive decline, Depression, Osteoporosis

Estrogen * Osteoporosis, Cognitive decline

Vitamin D Osteoporosis, Sarcopenia, poor mobility

* Replacement not recommended

Prevention of Frailty

Address Nutrition, Function & Co-morbiditiesDiabetes ControlStroke preventionCAD, PAD treatmentFall prevention, Physical therapy interventionsExerciseNutritional evaluationsImmunizations, Vaccinations

F. R. A. I. L. T. Y.

Food intake: Maintain nutrition, protein intake, fiber intakeIn between meal supplementsAppetite enhancers such as marinol and megestrolSupplement for any nutritional deficiencies

B12, B6, Folate

F. R. A. I. L. T. Y.

Resistance exercise 3x/ weekResistance with weights or bands builds muscles and helps reduce joint stiffness and painExercise has been shown to

Increase muscle strengthIncrease muscle sizeIncrease gait velocityIncrease mobility

Case 2A 68 yr old retired accountant is noted to have a 12 lb weight loss at his clinic visit for a diabetic foot ulcer, complicated by chronic osteomyelitisMeal intake reduced by 50%, but he has adequate resources and lives with his wife who is his caregiver. More fatigued and slow.Exam: CBG 209, cheerful, sarcopenia in UE and LE, draining heel wound,

How would you manage this patients weight loss?

Treatment StrategiesIdentify cause/causes and initiate targeted dental, medical, psychological, social, or community interventionThorough evaluation of all prescription and OTC medicationsNutrition counseling of patient and caregiversNutritional supplementationIncreased staff at mealtimes, food presentation, taste enhancement, change meal times (not 8-5 PM)Orexigenic drugs

Useful non-invasive screening testsComplete blood countLiver function tests (including alkaline phosphatase and bilirubin), measurement of LDHChest radiographyPatients with iron-deficiency anemia or symptoms likely to originate in the gastrointestinal tract, and patients with elevated liver enzyme levels on initial screening, should undergo

either endoscopy or UGI series or abdominal ultrasound

A rational approach to the treatment of weight loss in the elderly.

Identify and treatthe cause

No cause identified orno treatable condition

Improved prognosis+ quality of life

Weight gainDespite therapy no increase in weight

NUTRITIONAL SUPPORTFrequent small meals high inprotein and fatSupplements, night snacksPHYSICAL THERAPY

ExerciseOCCUPATIONAL THERAPY? ANABOLIC AGENTS

No weight gain

Poor prognosis

Consider enteralHyperalimentationNo terminal illlnessPt + family consent

Algorithm for managing weight loss in outpatientsDEHYDRATION? YES Treat

DECREASED FOOD AVAILABILITY?YES Refer to social

workerAPPETITE PROBLEM?

YES NO

MALABSORPTION?YES

TreatDELIRIUM?YES

Treat

NO

DEPRESSION?YES

Treat

NO

CONSIDER OREXIGENICS

NO

HYPERMETABOLISM?

YES

TreatLOOK FOR TREATABLE CAUSES? Malignancy ?other

NO

NO

Nutritional supplementation Palatable meals high in protein and fatsGive priority to ethnic food preferences Nutritional supplements as meal replacements or late night snacksLiquid energy supplements to swallow medications (Medpass 2.0 can treat weight loss in nursing homes)Begin aggressive efforts to assure adequate intake 48h after acute hospital admissionEnteral tube feeding (NG or J tube) has fewer problems, is more cost-effective and efficient than parenteral feeding (TPN)Peripheral parenteral nutrition (PPN) for short term support (10% dextrose, amino acids and intralipid)

Calculating enteral feeding requirements

Clinical condition Amount

Protein* Maintenance 1.2 – 1.5 g/kg/day

Stress* 1.5 – 2.0 g/kg/day

Calories# Maintenance 25 – 30 kcal/kg/day

Stress 30 – 40 kcal/kg/day

Sepsis 40 – 50 kcal/kg/day

Free water 30 – 35 ml/kg/day*Use IBW in obese persons# Use 120% IBW in obese persons

Pharmacological treatment of weight loss

Small gain in weight without evidence of decreased morbidity and mortality or improved function and quality of lifeOrexigenic (appetite-stimulating) and anabolic medications Only 4 have been studied in randomized trials

Orexigenic Drugs

AGENT MECHANISM OF ACTION

Megestrol acetate Progestagen/anticytokineDronabinol CannabinoidCyproheptadine AntiserotoninAnabolic steroids (Oxandrolone) Mainly on muscleGrowth Hormone CentralCorticosteroids CentralMetoclopromide Increased gastric emptyingAntidepressants Treat depression(Mirtizapine) 5HT1 agonist, 5HT2 antagonist

MEGESTEROL ACETATEProgestational effect antagonizes estrogen (which ↓ food intake)Main effect is antagonism of cytokine production (TNFα, IL6)Increases appetite, weight, well being and fat massUseful in older persons with anorexia caused by cytokine excess (cancer, AIDS, P ulcers, arthritis, recurrent infections)May cause DVT or adrenal suppression

Orexigenic drugs and Their Side Effects

Cyproheptadine DeliriumTestosterone (gel,patch, Increased Hct

injection) Not with prostate CaFluid retentionSkin irritation

Oxymethalone/oxandrolone Liver dysfunctionnandrolone Renal failure

Growth hormone Carpal tunnel syndromeArthralgiasIncreased death

Megestrol acetate Deep vein thrombosishypoadrenalism

Dronabinol Delirium

Morley. Clin Geriatr Med Nov 2002

Addressing Weight Loss Issues

in the Elderly

Voluntary Weight LossDietary modification required because of OW/OBWeight modification because of diagnosed medical conditionsPersonal feelings of OW

Involuntary Weight LossDepression (> in LTCF)CancerCardiac disorderAlcoholism Benign gastrointestinal diseasesMedicationPolypharmacyCognitive impairment

Nutrition Assessment is Key

Physiologic Anorexia of Aging

By the age of 65 years, approximately 50 percent of Americans have lost teeth!

Weight loss should NEVER be considered as part of

the normal aging process.

Nutritional AssessmentAnthropometric measuresGeneral physical assessmentDietary assessmentSelf assessmentMedication reviewEnvironmental scan

TreatmentTeam approachUse of flavor enhancersSmall, frequent mealsExerciseMedicationsFeeding tubes

Voluntary Weight Loss IssuesPlanningExercise↓ fat usually preferredSmall, frequent meals/snacks

!!! REMEMBER !!!

Eating food is one of life’s greatest pleasures as we mature!

QUESTIONS?Naushira Pandya, MD, CMD pandya@nova.eduCecilia Rokusek, EdD, RDrokusek@nova.edu