Malnutrition%20

1
Malnutrition the older patient

• James T. Birch, Jr., MD, MSPH
• Assistant Clinical Professor Dept. of Family
  Medicine
• Division of Geriatric Medicine
• Landon Center on Aging
• KU Medical Center
• February 19, 2007

2
Objectives

• Outline the ACOVE indicators for malnutrition for
  community-dwelling and hospitalized older persons
• Understand the physiologic changes that
  contribute to the problem
• Identify the risks of malnutrition in the elderly
  patient
• Discuss nutritional screening
• and assessment tools

3
Objectives

• Review basic nutritional requirements for the
  older patient
• Discuss options for nutritional intervention
• Review the ethical considerations for replacement
  of nutrition and hydration of the older patient
• Identify nutritional syndromes

4
Definition

• Malnutrition is the condition that develops when
  the body does not get the right amount of
  vitamins, minerals, and other nutrients it needs
  to maintain healthy tissues and organ function.
  The condition may result from an inadequate or
  unbalanced diet, digestive difficulties,
  absorption problems, or other medical conditions.
  However, there is no universally accepted
  clinical definition.

5

• Malnutrition is not something
• observed only in third-world countries.1
• Older persons suffer a burden of malnutrition
  that spans the spectrum from under- to
  overnutrition.2
• Malnutrition in the elderly is one of the
  greatest threats to health, well-being, and
  autonomy.
• 1. Kiseljak-Vassiliades, K., et al. Basic
  Nutrition for Successful Aging Part 1. Clinical
  Geriatrics, Vol. 14(4) April 2006
• 2. Geriatrics Review Syllabus A Core Curriculum
  in Geriatric Medicine, Sixth Edition (GRS6)
  American Geriatrics Society 2006
• 3. Francesco, VD, et al. The Anorexia of Aging.
  Digestive Diseases 25(2) 2007
  
  

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ACOVE - 3Quality indicators for Malnutrition

• ACOVE-3 indicators are comprised of
  IF-THEN-BECAUSE statements
• Apply to community-dwelling AND hospitalized
  older persons
• 8 quality indicators covering 4 domains
• Indicators are not supported by RCTs (except one)
  because most all studies have been small and
  involved persons who met narrow entry criteria
  or which lacked the highest quality of
  methodological rigor.
• Indicators are a product of literature review and
  expert panel consideration.

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ACOVE-3 quality indicators

• Indicator 1 ALL community-dwelling pts. Should
  be weighed at each physician office visit and
  these weights should be documented in the medical
  record BECAUSE this is an inexpensive method to
  screen for energy undernutrition and obesity that
  has prognostic importance.

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ACOVE-3 quality indicators

• Indicator 2 IF a vulnerable elder has
  involuntary wt. loss of gt 10 of body wt. over
  one year or less, THEN wt. loss (or a related
  disorder) should be documented in the medical
  record as an indication that the physician
  recognized malnutrition as a potential problem
  BECAUSE some patients with wt. loss have
  potentially reversible disorders.

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ACOVE-3 quality indicators

• Indicator 3 IF a community-dwelling vulnerable
  elder has documented involuntary wt. loss or
  hypoalbuminemia (lt 3.5g/dL), THEN she or he
  should receive an evaluation for potentially
  reversible causes of poor nutritional intake
  BECAUSE there are many treatable contributors to
  malnutrition.

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ACOVE-3 quality indicators

• Indicator 4 IF a community-dwelling vulnerable
  elder has documented involuntary wt. loss or
  hypoalbuminemia (lt 3.5g/dL), THEN he or she
  should receive an evaluation for potentially
  relevant comorbid conditions including
  Medications that might be associated with
  decreased appetite (digoxin, fluoxetine,
  anticholinergics), depressive symptoms, and
  cognitive impairment BECAUSE each of these
  represents a treatable contributor to
  malnutrition.

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ACOVE-3 quality indicators

• Indicator 5 IF a vulnerable elder is
  hospitalized, THEN his or her nutritional status
  should be documented during the hospitalization
  by evaluation of oral intake or serum biochemical
  testing (e.g., albumin, prealbumin, or
  cholesterol) BECAUSE each of these measures has
  prognostic significance and can identify older
  persons at risk of malnutrition or adverse
  outcomes (complications, prolonged length of
  stay, in-hospital and up to one-year mortality).

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ACOVE-3 quality indicators

• Indicator 6 IF a hospitalized vulnerable elder
  is unable to take foods orally for more than 72
  hours, THEN alternative alimentation (either
  enteral or parenteral) should be offered BECAUSE
  such patients are at high risk of malnutrition
  that can improve with caloric supplementation

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ACOVE-3 quality indicators

• Indicator 7 IF a vulnerable elder who was
  hospitalized for a hip fracture has evidence of
  nutritional deficiency (thin body habitus or low
  serum albumin or prealbumin), THEN oral or
  enteral nutritional protein-energy
  supplementation should be initiated
  post-operatively BECAUSE RCTs have indicated
  better outcomes in these pts.

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ACOVE-3 quality indicators

• Indicator 8 IF a vulnerable elder with a stroke
  has persistent dysphagia at 14 days, THEN a
  gastrostomy or jejunostomy tube should be
  considered for enteral feeding BECAUSE this
  method of feeding has improved outcomes compared
  to oral feeding.

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Contributors to risk of malnutrition

• The elderly are at higher risk of developing
  protein-calorie malnutrition and other vitamin
  and mineral deficiencies.
• The frequency of these events increases with
  advancing age due to problems such as poor
  dentition, loss of taste, difficulty swallowing,
  malabsorption, and drug-nutrient interaction
  

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Contributors to risk of malnutrition

• Other physical limitations such as inability to
  obtain necessary food due to lack of
  transportation and dependence on others for
  shopping, lack of financial resources, and
  functional limitations can contribute to
  nutritional deficiencies

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Contributors to risk of malnutrition

• Non-perishable foods frequently contain high
  amounts of sodium and nitrates, and processing
  can remove vitamins.
• Many drugs cause anorexia, gustatory changes, and
  anosmia as major side effects.
• Medications can also interfere with
  nutrient availability

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Risk Factors for Poor Nutrition Status
Alcohol or substance abuse Limited mobility, transportation
Cognitive dysfunction Medical problems, chronic diseases
Decreased exercise Medications
Depression, poor mental health Poor dentition
Functional limitations Restricted diet, poor eating habits
Inadequate funds Social isolation
Limited education (see MEALS ON WHEELS on pocket card)
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Physiology-the anorexia of aging
20
Physiology-the anorexia of aging
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Physiology

• Changes in physiology, metabolism, body
  composition, and physical function in the older
  patient may alter nutritional requirements, so
  that standards applicable to younger patient or
  middle-aged adults cannot be applied to the
  elderly

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Physiology

• Changes in body composition
• Decreased bone mass
• Decreased lean mass
• Decreased water content
• Increased total body fat (greater
  intra-abdominal fat stores)
• Decline in organ function is highly variable
  among individuals and may affect assessment and
  intervention options

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Physiology

• Serum albumin is a recognized risk indicator for
  morbidity and mortality but is not an indicator
  of malnutrition because it lacks sensitivity and
  specificity.
• A modest decline does occur with aging
• Half-life is 20 days
• Sensitive to hydration state and presence of
  inflammation, surgery, and other severe disease

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Physiology

• Hypoalbuminemia in the
• A. Community Setting
• Functional limitation
• Sarcopenia
• Increased health care use
• Mortality

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Physiology

• Hypoalbuminemia in the
• B. Hospital setting
• Increased length of stay
• Complications
• Readmissions
• Mortality

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Physiology

• There are some reports which express the use of
  caution with using albumin as a measurement of
  nutritional status in hospitalized patients.
  It is inversely correlated with markers of
  inflammatory activity (ESR, CRP) and can behave
  as an acute-phase reactant, with markedly reduced
  levels in the setting of acute illness.

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Physiology

• Prealbumin half-life 48 hours
• Responds rather quickly to increased protein
  intake
• Controversial with regards to its use as a marker
  of malnutrition
• Best used in conjunction with other parameters
  (i.e. exam, BMI, CRP, hx of wt. loss, and various
  nutritional assessments)
• Also affected by changes in transcapillary escape
  due to infection, inflammation, etc.

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Physiology

• Cholesterol
• Serum cholesterol has been linked to nutritional
  status. Levels lt160mg/dl have been detected in
  patients with malignancy or other severe disease
  states. Community-dwelling elderly with both
  hypoalbuminemia and hypocholesterolemia exhibit
  higher rates of functional decline and mortality
  than those with either one alone.

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Drugs that can cause ANOREXIA

• digoxin
• phenytoin
• SSRIs / lithium
• Ca channel blockers
• H2 receptor antagonists / PPIs
• Any chemotherapy
• metronidazole

• narcotic analgesics
• K supplements
• furosemide
• ipratropium bromide
• theophylline
• spironolactone
• levodopa
• fluoxetine

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Drugs can interfere with senses of taste and smell

• More than 250 medications reportedly disturb
  gustatory sensation
• More than 40 drugs reportedly disturb the sense
  of olfaction
• A few of these agents have been objectively
  determined to affect these functions
  via experiments,
  clinical trials, or intensity
  scaling

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Drugs That Interfere With Gustation (taste) and
Olfaction (smell)

• Gustation
• Allopurinol
• Amitriptyline
• Ampicillin
• Baclofen
• Dexamethasone
• Diltiazem
• Enalapril
• Hydrochlorothiazide
• Imipramine
• Labetalol
• Mexiletine
• Ofloxacin
• Nifedipine
• Phenytoin
• Promethazine
• Propranolol
• Sulfamethoxazole
• Tetracyclines

• Olfaction
• Amitriptyline
• Codeine
• Dexamethasone
• Enalapril
• Flunisolide
• Flurbiprofen
• Hydromorphone
• Levamisole
• Morphine
• Pentamidine
• Propafenone

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Drug-nutrient interactions

• Many of the aforementioned drugs and others
  interfere with the absorption of various vitamins
  and minerals
• Examples
• Antacids- Vitamin B12, folate, iron, total kcal
• Diuretics- Zn, Mg, Vitamin B6, K, Cu
• Laxatives- Ca, Vitamins A, B2, B12, D, E, K

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Drug-Nutrient Interaction
Drug Reduced Nutrient Availability
Alcohol Zinc, vitamins A, B1, B2, B6, folate, vitamin B12
Antacids Vitamin B12, folate, iron, total kcal
Antibiotics, broad-spectrum Vitamin K
Digoxin Zinc, total kcal (via anorexia)
Diuretics Zinc, magnesium, vitamin B6, potassium, copper
Laxatives Calcium, vitamins A, B2, B12, D, E, K
Lipid-binding resins Vitamins A, D, E, K
Metformin Vitamin B12, total kcal
Phenytoin/Salicylates Vitamin D, folate/Vitamin C, folate
SSRIs Total kcal (via anorexia)
Trimethoprim Folate
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Basic Nutritional Requirements for the Older
Patient

• Estimated total daily energy need (based on body
  weight)
• 25-30 kcal/kg/day
• Estimated total daily energy need (based on basal
  energy expenditure BEE)
• Harris-Benedict Equation
• Male BEE 66 (13.7 x kg) (5 x cm) (6.8 x
  age)
• Female BEE 655.1 (9.563 x kg) (1.850 x cm)
  - (4.676 x age)
• Results should be multiplied by 1.5 to estimate
  energy expenditure of ill elderly patients

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Basic Nutritional Requirements for the Older
Patient

• Carbohydrates should comprise 45-65 of total
  calories
• Fat should comprise 20-35 of total calories
• Protein should comprise
• 10-35 of total calories
• Fluid 30ml/kg/day or 1ml per kcal intake

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Basic Nutritional Requirements for the Older
Patient

• Estimation of protein
• (0.8 to 1.5)gm/kg/day
• Restriction of these amounts may be indicated in
  renal or hepatic insufficiency
• Estimation of fiber (complex carbohydrates are
  the preferred fiber source)
• Men 30 gm/day
• Women 21 gm/day
• (see the 1-30-30 rule on the pocket card)

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Nutritional Screening and Assessment

• Nutrition Screening Initiative (NSI)
• collaborative effort of AAFP, ADA, and the
  National Council on Aging
• NSI completed a study in 1996, revealing evidence
  that older patients admitted to the hospital in
  poor nutritional states had longer stays and
  increased rates of complications than
  well-nourished patients.
  
• 
  
• Bagley, B Nutrition and Health (Editorial)
  AFP, 57(5) March 1, 1998

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Nutritional Screening and Assessment

• The NSI developed a screening tool that can be
  completed by patients, family members, or a
  health care professional
• The tool consists of 10 questions which are
  scored and placed in 3 categories
• No nutritional risk 0-2 points
• Moderate nutritional risk 3-5 points
• High nutritional risk gt6 points

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Nutritional Screening and Assessment

• NSI (points apply to YES answers)
• I have an illness or condition that made me
  change the kind and/or amount of food I eat (2)
• I eat fewer than two meals per day (3)
• I eat few fruits or vegetables, or mild 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 3 or more different prescribed or OTC
  drugs per day (1)
• Without wanting to, I have lost or gained 10 or
  more pounds in the last six months (2)
• I am not always physically able to shop, cook
  and/or feed myself (2)

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Nutritional Screening and Assessment

• Mini Nutritional Assessment (MNA) is a validated
  screening and assessment tool for identifying
  elderly patients with or at risk for malnutrition
• Developed by the Nestlé Research Center, in
  collaboration with hospital clinicians

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Nutritional Screening and Assessment

• The MNA obviates the need for blood tests to
  screen and monitor a patients nutritional status
• Composed of two sections Screening and
  Assessment

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Nutritional Screening and Assessment

• MNA Screening
• In the screening section, five questions are
  asked, and the patient's BMI (Body Mass Index) is
  calculated, using the patient's height and
  weight. From these six items, a score is
  calculated, which will indicate whether there is
  possible malnutrition
• Screening score (max. 14 pts)
• gt 12 pts Normal not at risk
• lt 11 pts Poss. malnutrition go to assessment

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Nutritional Screening and Assessment

• MNA Assessment
• Clarifies whether there is a future risk of
  malnutrition, or if malnourishment is currently
  present. The assessment section is comprised of
  10 questions, and two anthropometric measures
  mid-arm circumference and calf circumference.
• Scoring (max. 16 pts) when added to screening
  score, total max is 30 pts. If total is 17-23.5
  pts, pt is at risk of malnutrition and if lt17
  pts, the pt is malnourished.

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Nutritional Screening and Assessment

• The MNA has demonstrated acceptable internal
  consistency, inter-observer reliability, and
  validity in studies of community-dwelling,
  hospitalized, and nursing home elderly
  individuals around the world and in the U.S.
  
• Beck, A., et al. European Journal of Clinical
  Nutrition. Nov 2001, Vol 55(11) 1028-33

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Nutritional Screening and Assessment

• Limitations of use of MNA
• Lack of familiarity with the requirement of
  measuring both mid-arm and calf circumference

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Nutritional Screening and Assessment

• Geriatric Nutritional Risk Index (GNRI) requires
  measurements of height, albumin, and weight at
  admission (also ideal weight as calculated from
  the Lorentz equation). Nutritional risk is
  graded based on results of calculations. It is a
  more reliable prognostic indicator of morbidity
  and mortality in hospitalized elderly. Low
  albumin and elevated CRP correlate statistically
  with increased nutritional risk (stronger than
  with prealbumin)

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Body Size Classification
Body Size Body Mass Index (kg/m²)
Underweight lt 18.5
Normal weight 18.5-24.9
Overweight 25-29.9
Obesity 30
Extreme Obesity 40
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Nutritional Syndromes

• Undernutrition-3rd leading condition in hospital
  and home care sites and 4th leading condition in
  office practice and nursing homes for which QI
  efforts would improve the functional health of
  older persons.

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Nutritional Syndromes

• Undernutrition it is often clinically difficult
  to physically distinguish cachexia from
  wasting
• Cachexia (REE is increased)
• Wasting (REE is decreased)
• REE Resting energy expenditure

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Nutritional Syndromes

• Obesity prevalence extends to the 60-70 age
  group
• Adverse outcomes associated with obesity include
  impaired functional status (esp. BMIgt35),
  increased health care resource use and increased
  mortality
• Poor diet quality and micronutrient deficiencies
  are common in obese elderly pts., especially
  women who live alone

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Nutritional Syndromes

• In the older obese patient, the focus should be
  on attaining a healthy weight to promote improved
  function, overall health, and quality of life
• A combination of dietary change, behavior
  modification and increasing activity or exercise
  are appropriate for most elderly obese patients.

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Nutritional Syndromes

• However, homebound elderly are growing in number
  among the elderly obese. For those with frailty
  and obesity, the emphasis may be better placed on
  preservation of strength and flexibility rather
  than on weight reduction.

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Nutritional interventions

• PREVENTION is easier than treatment
• Intake improved by catering to food preferences
  avoid therapeutic diets with no known clinical
  value
• Prepare patients for meals with hand/mouth care
  proper positioning
• Assist those who need assistance
• Use herbs and spices to compensate for the losses
  of senses of taste and smell

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Nutritional interventions

• Avoid rushing through a meal
• Meals-On-Wheels wherever possible (Title III of
  Older Americans Act)
• Provide dietary supplements
• Micronutrient supplements
• Calcium and vitamin D
• (1200mg/800 I.U.)

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Nutritional interventions

• Vitamin E has not been shown to reduce the
  progression of Alzheimers disease or prevent
  coronary artery disease, but has been associated
  with a higher risk of hemorrhagic stroke
  naturally occurring vitamins may do a better job
  of preventing cardiovascular disease and
  mortality.

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Nutritional interventions

• It has been suggested that multivitamins and
  antioxidants may help to prevent age-related
  cataracts and macular degeneration
• Ask about and document all medications and
  supplements being taken. Review the necessity,
  safety, potential risks, and adverse effects with
  the patient.

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Nutritional interventions

• DRUG TREATMENT
• Appetite stimulants
• Cytokine-modulating agents
• Trophic agents

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Nutritional interventions

• Appetite stimulants
• mirtazapine (Remeron) 3.75-30mg PO at bedtime
  enhances serotonin via antagonism of the 5-HT3
  receptor
• cyproheptadine (Periactin) 2-4mg PO orally with
  meals serotonin and histamine antagonist with
  some anticholinergic properties and potential for
  confusion in the elderly

59
Nutritional interventions

• Appetite stimulants
• Megestrol (Megace) 320 800 mg PO in four
  divided doses. Wt. gain is primarily fat
  associated with increased risk of DVT in nursing
  home patients
• Dronabinol (Marinol) 5-15mg/M2/day a cannabinoid
  associated with somnolence and dysphoria in older
  persons

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Ethical issues

• For the nursing home patient, standards of care
  stipulate that a resident maintain acceptable
  parameters of nutritional status (weight, protein
  levels) unless the clinical condition is one
  wherein this is not possible, and a resident
  should receive a therapeutic diet when there is a
  problem.

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Ethical issues

• Adequate nutrition and hydration should always be
  provided to the elderly patient unless invasive
  nutritional support is refused by a
  fully-competent patient (document in written form
  that pt. has been informed of potential
  consequences of this choice with witnesses) or
  the terminally ill patient has executed a living
  will or advance directive that excludes
  artificial feeding in the event of unexpected
  death or terminal illness.

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Ethical issues

• Use caution with initiation of artificial
  nutrition and hydration in demented patients.
  This has not been demonstrated to improve life
  expectancy or quality of life.
• Appropriate counseling of patient, family, and/or
  surrogate of the consequences of withholding
  nutrition and feeding is obligatory!
• Consider palliative care in the setting of severe
  or end-stage dementia, and in those cases where
  living wills specify the withholding of
  artificial nutrition and hydration.

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SUMMARY

• Malnutrition is remarkably common in the older
  adult
• The risk of malnutrition in the elderly is high
  even in the absence of clinical or social risk
  factors due to the primitive so-called anorexia
  of aging.
• Limitations in functional capacity, dentition,
  and support systems contribute to the problem
• Medications can and do adversely impact
  nutritional status
• Use of one of the screening tools can identify
  undernourished individuals whose problems are
  amenable to intervention

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SUMMARY

• Prevention is best, but implementation of
  interventions as early as possible (lt 3 days
  since diagnosis) enhance more favorable outcomes
• Prealbumin alone is probably not a good parameter
  for identifying malnutrition but when combined
  with other measures such as serum albumin,
  cholesterol, BMI, or CRP it can be more useful.
• Low albumin and elevated CRP can be significant
  risk indicators while not being diagnostic of
  the presence of malnutrition.

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SUMMARY

• Clarify patients advance directives whenever
  possible before initiating tube feedings or other
  artificial nutrition and hydration.
• Only a few of the quality indicators for
  malnutrition have evidence to support them, but
  the 8 ACOVE indicators weve discussed can serve
  as measures that may differentiate between
  quality and substandard care.

66
References

• Nestle Nutrition MNA (Mini Nutritional
  Assessment) http//www.nestle-nutrition.com/tools/
  mna.aspx
• Malnutrition, Chap. 24 Geriatrics Review
  Syllabus, Sixth Edition American Geriatrics
  Society, 2006 PP 174-80
• Reuben, D. Quality Indicators for Malnutrition
  for Vulnerable Community-Dwelling and
  Hospitalized Older Persons RAND Health
  http//www.rand.org/health/projects/acove/quality_
  indicators.html
• Bagley, B. Nutrition and Health-Editorial
  American Family Physician March 1, 1998 57(5)-
• Beck, A.M., et al. A six months prospective
  follow-up of 65 y-old patients from general
  practice classified according to nutritional risk
  by the Mini Nutritional Assessment Euro J of
  Clin Nutrition, 2001, Vol. 55 1028-33
• Lantz, M.S. Failure to Thrive Clinical
  Geriatrics, March 2005, 13(3) pp 20-23
• Kiseljak-Vassiliades, K., et al. Basic Nutrition
  for Successful Aging Part 1 Clinical
  Geriatrics, April 2006, 14(4)pp 16-24
• Shenkin, A. Serum Prealbumin Is It a Marker of
  Nutritional Status or of Risk of
  Malnutrition?-Editorial Clinical Chemistry
  52(12), 2006
• Devoto, G., et al. Prealbumin Serum
  Concentrations as a Useful Tool in the Assessment
  of malnutrition in Hospitalized Patients.
  Clinical Chemistry 52(12)2281-85, 2006
• Francesco, V.D., et al. The Anorexia of Aging
  Digestive Diseases 25(2)129-137 2007