1. Geriatric Malnutrition
Richard Allan Bettis, Fourth-Year Pharm.D. Candidate
Preceptor: Dr. Ali Rahimi
University of Georgia College of Pharmacy

2. Background
A frequent and common condition in the elderly associated with:
Increased morbidity
Increased mortality
Increased hospitalizations
Reduced quality of life

3. Frequency
Occurs in 5-10% of older patients residing in nursing homes or long-term care facilities
Occurs in up to 50% of older patients when discharged from the hospital
Most reversible or treatable causes of undernutrition are frequently overlooked by physicians

4. Background
Undernutrition or malnutrition can be a result of two likely scenarios:
Protein energy wasting characterized primarily by weight loss
Individual nutrient deficiencies characterized by a lack of single nutrients and seen more commonly in older persons

5. The Body & Energy
Total energy expenditure based upon an individual’s basal metabolic rate (or BMR)
Energy required for physical activity and creating fuel reserves after feeding
Dependent upon age, weight, gender, and activity level
Women < men with BMR
Weight > BMR due to more active tissue in larger body
Energy requirements increase with activity

6. Energy & Aging
BMR decreases with age regardless of constant body weight
Result of muscle tissue replacement by less metabolically active adipose tissue
From nestle webinar

7. Energy & Nutrients
Protein, carbohydrates, and fat account for a percentage of total calories to meet nutritional needs
Harper's Illustrated Biochemistry, 29e Table 16–1 Energy Yields, Oxygen Consumption, and Carbon Dioxide Production in the Oxidation of Metabolic Fuels

8. Energy & Nutrients
Energy yield varies between different types of foods
Harper's Illustrated Biochemistry, 29e Table 16–1 Energy Yields, Oxygen Consumption, and Carbon Dioxide Production in the Oxidation of Metabolic Fuels

9. Energy & Proteins
More energy from protein is highly encouraged and supported
Figure from nestle

10. The Body & Energy
Metabolic fuels in excess of energy expenditure results in obesity
A lack of metabolic fuel to supply energy expenditure results in emaciation, wasting, marasmus, kwashiorkor
Both situations are associated with increased mortality

11. Nutrient Deficiency
A lack of single nutrients resulting in less common disease states
Very rarely seen in developed countries except occasionally in older persons
Table 1- Morley JE

12. Weight Loss & Mortality
When older patients lose weight they have a doubling in their risks for death
Even if the patient is overweight!
Weight loss increases likelihood of:
Hip fractures
Institutionalization
Downward spiral of negative events
Weight loss is the best sign of treatable undernutrition

13. Caregiver Perceptions
Weight loss is the best sign of treatable undernutrition or malnutrition

14. Nutritional Status
There is no gold standard for diagnosis of malnutrition
There are several quick assessment tools
Better indicators of illness b/c inflammatory cytokines play a significant role in reducing these proteins
Harrisons principles of internal med 18e tablet76-1

15. Nutritional Assessment Tools
Mini-Nutritional Assessment (MNA)
Most established screening tool for older adults
Difficult to distinguish between patients at risk for malnutrition and frailty
Not applicable if patients are non-communicable
Non-communicable pts (dementia, alzheimers, stroke, etc)

16. Nutritional Assessment Tools
Simplified Nutritional Assessment Questionnaire (SNAQ)
High sensitivity and specificty to detect weight loss over next 6 months
Malnutrition Universal Screening Tool (MUST)
Uses BMI, weight loss, and an acute disease effect score
Predictor of mortality and length of stay in hospital

17. Simplified Nutritional Assessment Questionnaire (SNAQ)

18. Nutritional Assessment Tools
Nutritional Risk Screening (NRS)
Proposed universal screening tool for malnutrition in hospitalized patients
Assesses BMI, weight loss, appetite, and severity of disease
Applicable to more types of patients
Five item test – age, BMI, appetite, accidental wt loss, severity of acute illness

19. Nutritional Markers Serum protein assays
Albumin, prealbumins, retinol binding proteins
Not specific to detect malnutrition or changes in nutritional status
Reductions in these proteins are better indicators of illness
Better indicators of illness b/c inflammatory cytokines play a significant role in reducing these proteins

20. Nitrogen Balance Normally at equilibrium Positive nitrogen balance
Intake = output
No change in total body content of protein
Positive nitrogen balance
Growing children, pregnancy, recovery from protein loss
Excretion of nitrogenous compounds is less than intake
Net retention of nitrogen is in the body as protein

21. Nitrogen Balance
Nitrogen balance studies show consuming more than 14% of energy source from protein is more than enough to increase muscle protein synthesis

22. Amino Acids Essential Non-essential Cannot be synthesized in the body
If any of these are lacking, then nitrogen balance will not be possible
Histidine, isoleucine, leucine, lysine, methionine, phenylalanine, threonine, tryptophan, and valine
Non-essential
Can be synthesized from the body or from essential amino acids
Not necessary for nitrogen balance

23. Weight Loss Complications
Severe weight loss leads to protein malnutrition and a downward spiral of adverse effects
Loss of weight also leads to loss of:
Fat
Muscle
Bone
Albumin
Thymic atrophy = thymus (lymphoid tissue)
Table 2- Morely JE

24. Weight Loss Cause
A lack of metabolic fuel to supply energy expenditure results in weight loss, emaciation, and wasting

25. Weight Loss Causes The “Triple Threat”
Six major causes of weight loss in older patients:
Anorexia
Cachexia
Sarcopenia
Malabsorption
Hypermetabolism
Dehydration
The
“Triple Threat”

26. “Anorexia of Aging” Anorexia is an independent predictor of mortality
Reduction in food intake as individual’s age
Males – 30%
Females – 20%
Causes of anorexia in older patients are multifactorial
Physiological
Psychological
Drug or disease induced

27. “Anorexia of Aging”
Causes of anorexia in older patients are multifactorial
Physiological
Psychological
Depressed or cognitively impaired patients
Disease or drug induced
Decreased appetite due to acute disease or medication effects

28. “Anorexia of Aging” Physiological changes
Decrease in taste and olfaction resulting in decreased enjoyment of food
Decrease in gastric emptying resulting in early satiation signals
Changes in gut hormones involved in (satiety or feelings of fullness)

29. Gut Hormones

30. “Anorexia of Aging” Gut hormone changes and contribution to anorexia
Increase in cholecystokinin (CKK) release and sensitivity resulting in greater satiating effects
Increase in leptin levels resulting in increased satiety after meals
Reduced sensitivity to ghrelin associated with reductions in hunger sensation

31. Anorexia is multifactoral
“Anorexia of Aging”
Anorexia is multifactoral

32. Causes of Weight Loss The “Triple Threat”
Six major causes of weight loss in elderly:
Anorexia
Cachexia
Sarcopenia
Malabsorption
Hypermetabolism
Dehydration
The
“Triple Threat”

33. Cachexia
Severe wasting disorder characterized by loss of both fat and muscle
Caused by effects from the overproduction of pro-inflammatory cytokines resulting from a variety of illnesses
Marked by changes in other markers:
Increases C-reactive protein
Decreases serum albumin
Causes anemia

34. Cytokine Overproduction
Usually overlapped with anorexia and sarcopenia in older individuals
Increases resting metabolic rate resulting in higher metabolic demands
Decreases both gastric emptying and intestinal motility

35. Causes of Weight Loss The “Triple Threat”
Six major causes of weight loss in older patients:
Anorexia
Cachexia
Sarcopenia
Malabsorption
Hypermetabolism
Dehydration
The
“Triple Threat”
IF YOU DON’T USE IT YOU LOSE IT

36. Sarcopenia In Greek, translates literally to “poverty of flesh”
Characterized by muscle atrophy and a loss of muscle functionality
Associated with aging and prevented by exercise
Sarcopenia
--image

37. The “Triple Threat”
An older sedentary patient with COPD experiences an overlap of all 3.

38. Causes of Weight Loss
Six major causes of weight loss in older patients:
Anorexia
Cachexia
Sarcopenia
Malabsorption
Hypermetabolism
Dehydration

39. Malabsorption
Most commonly caused by celiac disease and pancreatic insufficiency in older patients
Serum levels of vitamin A and beta-carotene used to diagnose fat malabsorption
Screenings for various immunoglobins and antibodies used to diagnose celiac disease

40. Causes of Weight Loss
Six major causes of weight loss in older patients:
Anorexia
Cachexia
Sarcopenia
Malabsorption
Hypermetabolism
Dehydration

41. Hypermetabolism When energy demand exceeds nutrient intake
Most commonly caused by hyperthyroidism and pheochromocytoma in older patients
Blepharoptosis – upper eyelid drooping, relaxation – “apathetical look”
Exophthalmos – bulging out of eyes

42. Hypermetabolism Apathetic hyperthyroidism Pheochromocytoma Weight loss
Atrial fibrillation
Proximal muscle weakness
Blepharoptosis (not exophthalmos)
Pheochromocytoma
Adrenal gland tumor
Consider if hypertensive and losing weight
Blepharoptosis – upper eyelid drooping, relaxation – “apathetical look”
Exophthalmos – bulging out of eyes

43. Causes of Weight Loss
Six major causes of weight loss in older patients:
Anorexia
Cachexia
Sarcopenia
Malabsorption
Hypermetabolism
Dehydration

44. Dehydration Reduced total body water
Normal daily fluid requirement is 30ml/kg body mass
Table from nestle

45. “Anorexia of Aging”
Causes of anorexia in older patients are multifactorial
Physiological
Psychological
Drug or disease induced

46. “Anorexia of Aging” Psychological manifestations
Reactive depression
Change in living conditions
Food refusal behaviors
All are not uncommon and can lead to weight loss and malnutrition

47. Depression
Most common cause of treatable anorexia in community and institutional settings
Late-life depression is significantly underdiagnosed in older persons
Corticotropin-releasing hormone (an anorexogenic) is elevated in patients with depression
Eating disorders commonly manifest 48-80yo

48. Relocation
Change in living conditions evokes psychological anorexic responses
Late-onset paranoia
Fear of poisoning
Indirect self-destructive behavior (ISDB)
An unconscious method of suicide
May be due to trauma of relocation

49. Food Refusal Behaviors
Most prevalent in cognitively impaired
Common in demented elderly patients due to agnosia or dyspraxia
Difficulty interpreting sensory data and not recognizing an object as food
Difficulty with motor movements and unable to open mouth despite intentions to
Common refusal behaviors in intermediate-stage Alzheimer’s patients would be:
Distraction from eating
Verbal refusal to eat
Agnosia- not recognizing food as food
Dyspraxia – motor difficulties that can affect planning of movements

50. Food Refusal Behaviors
Deliberate refusal
Indirect self-destructive behavior (ISDB)
Reflexive withdrawal behavior
Dislike of a certain food
Protest against certain caregiver
It is crucial to distinguish between refusal to eat and lack of ability to eat
Patients with dysphagia may refuse food

51. Indirect self-destructive behavior (ISDB)
Pictorial essay that showed an 81yo demented father who decided one day he was going to
‘‘The grandfather, 81, one day removed his false teeth and announced that he was no longer going to eat or drink. Three weeks later, to the day, he died.”

52. Management Nutrition Refusals
Berry EM Table II

53. Energy Wasting & Weight Loss
The basics:
Provide adequate food supplementation
Early on:
Food variety
High calorie food
Calorie supplements
Focus on:
Diagnosing causes
Treating treatable causes

54. “Anorexia of Aging”
Common causes of pathological and treatable anorexia in the elderly:
Depression
Medications
Therapeutic diets
Cancer
Uncontrolled pain
Medications = polypharmacy
Avoid therapeutic dieting in older, frailer pts
Cancer accounts for <10% of undernutrition in these pts
Alleviating and managing pain can increase appetite

55. Treatable Causes
Table 4- Morley JE “Meals on Wheels” mnemonic

56. Management
Calorie supplementation decreases mortality and hospital lengths of stay
Cachexia shown to be responsive to protein calorie supplementation
Increase in 6-minute walks
Decreased hospitalizations

57. When? Oral calorie supplements between meals
Avoid supplementing calories during meals
Reduction in food intake
No net increase in total caloric ingestion

58. How? Environmental considerations Behavioral modifications
Improve food taste
Avoid therapeutic diets with limited justification
Allow extra time to eat during mealtimes
Spend time feeding impaired patients
Other aesthetic considerations
Behavioral modifications
Improve quality of relationships between patient and feeder
Use touch or verbal cueing

59. What Else? Orexigenic medications available to stimulate appetite
Megestrol acetate
Dronabinol
Testosterone

60. Megestrol Acetate
Orexigenic agent with mechanisms to increase food intake and cause weight gain
Progestational agent
Corticosteroid activity
Mild testosterone-like activity
More effective in women than men
Reduces cytokine activity

61. Megestrol Acetate Side effects Deep vein thrombosis
Severe constipation in older patients
Fluid retention
Not recommended for sedentary patients
Not recommended for use >3 months at one time
Synergistic effects when combined with olanzapine

62. Dronabinol
Orexigenic agent and extract of tetrahydrocannabinol (THC) with mechanisms to produce small increases in appetite and weight gain
Used in palliative care settings:
Reduces nausea
Increases enjoyment of both food and life

63. Other Agents Testosterone Agents with roles in cachexia treatment
Produces weight gain
Decreases hospitalizations in frail older patients
Used in combination with caloric supplementation
Agents with roles in cachexia treatment
Low dose steriods (5mg prednisone daily)
Selective androgen receptor modulators (ostarine)
Activin IIR decoy antibodies
Myostatin antibodies
5mg prednisone daily improved well being and appetite in some pts (esp chronic cardiac/pulm cachexia)

64. Medications Medications can cause weight loss by:
Affecting food intake
Diminishing appetite
Causing nausea, vomiting, or GI irritation
Altering taste and smell
Induce depression
Should consider using a minimum effective dose or discontinuing medications opposing weight gain or caloric supplementation

65. Medications Some medications may cause anorexia Theophylline Digoxin
Neuroleptics
SSRIs

66. Nutritional Rehabilitation
Specialized nutrition regarded as a last resort
Parenteral feeding
Enteral feeding
Overused in the U.S. especially in patients with dementia
No evidence of a reduction in mortality or improvements of quality of life

67. Specialized Nutrition
Only small fraction of malnourished patients will benefit from specialized nutritional support (or SNS)
In elderly or chronically ill patients the decision to specialty feed is based upon whether or not quality of life will be extended
Multiple considerations before decision to implement SNS

68. Will quality of life be extended?
Algorithm
Will quality of life be extended?
PCM – protein calorie malnutrition
SNS – specialized nutrition support

69. Specialized Nutrition
Enteral or “tube feeding”
Tube placed into the gut to deliver liquid formulations which contain all essential nutrients
Parenteral or “intravenous feeding”
Infusion of nutrient solutions directly into the bloodstream via peripherally located or centrally located vein
Both associated with risk and discomfort
Both difficult to stop once started

70. Specialized Nutrition Risk
Safest route is to avoid SNS
Closely monitor and ensure adequate oral food intake
Adding oral liquid supplement
Using an appetite stimulant in eligible patients

71. Enteral Feeding Preferred route – “If the gut works, then use it”
Maintains gut functionality
Less risk for infection
Intestinal tolerance limited by gastric retention or diarrhea
Often required in patients with:
Anorexia
Impaired swallowing or dysphagia
Bowel disease

72. Parenteral Feeding Less preferred route
Greater risk for infection
Higher chance of inducing hyperglycemia
Often required in patients with:
Prolonged ileus or obstruction
Severe hemorrhagic pancreatitis

73. Electrolytes & Specific Nutrients

74. Trace Metals

75. Ethics & Controversy Food refusals
Distinguishing between competent and demented patients
Identifying reversible symptoms such as unmanaged pain or depression
Caregiver decision to force feed patients

76. Ethics & Legality Enteral and parenteral feeds
Ordinary care or other medical treatment?
A patient has the right to refuse?
Supportive care while starving?

77. Management
Undernutrition or malnutrition can be a result of two likely scenarios:
Individual nutrient deficiencies characterized by a lack of single nutrients and seen more commonly in older persons
Protein energy wasting characterized primarily by weight loss

78. Nutrient Deficiencies
The basics:
Replace the target nutrient
Prevention is key
Important deficiencies in older patients:
Vitamin D
Iron
Folate
B-12
Zinc

79. Vitamin D Deficiency
Associated with fractures, muscle loss, falls, and increased mortality
25-hydroxy vitamin D levels are gradually reduced as part of the aging process
Levels are <30ng/mL in many older patients
Replacement of IU daily is appropriate for most older patients

80. Iron Deficiency Most commonly associated with iron deficient anemia
Characterized by low iron and ferritin levels
Once daily oral replacement for 6 weeks is appropriate for most older patients
Reticulocyte count after 1 week of therapy
Parenteral products may be necessary if no increase in reticulocytes (likely due to malabsorption)

81. Folate & B12 Deficiencies
Most commonly associated with
Both deficiencies characterized by elevated homocysteine levels
Methymalonic acid specific for B12 deficiency
Oral or injectable replacement is appropriate for most older patients
Vitamin B IU orally every day or 1000IU weekly injections x 4weeks

82. Zinc Deficiency Most commonly associated with:
Diabetics
Cancer patients
Individuals receiving diuretics
Role of replacement is uncertain

83. Recommended Intakes
From Nestle

84. Vitamin D Supplementation
From Nestle

85. Thank you !

86. rEFERENCES
Adams NE, Bowie AJ, et al. Recognition by medical and nursing professionals of malnutrition and risk of malnutrition in elderly hospitalised patients. Nutrition & Dietetics. 2008; 65: DOI: /j x
Bender DA, Mayes PA. Chapter 43. Nutrition, Digestion, & Absorption. In: Murray RK, Kennelly PJ, Rodwell VW, Botham KM, Bender DA, Weil PA, eds. Harper's Illustrated Biochemistry. 29th ed. New York: McGraw-Hill; Accessed February 6, 2013.
Bender DA. Chapter 44. Micronutrients: Vitamins & Minerals. In: Murray RK, Kennelly PJ, Rodwell VW, Botham KM, Bender DA, Weil PA, eds. Harper's Illustrated Biochemistry. 29th ed. New York: McGraw-Hill; Accessed February 6, 2013
Benelem B. Satiety and the anorexia of ageing. British Journal of Community Nursing. 2009; 14 (8):
Berry EM, Marcus EL. Disorders of Eating in the Elderly. Journal of Adult Development. 2000; 7 (2):

87. rEFERENCES
Bistrian BR, Driscoll DF. Chapter 76. Enteral and Parenteral Nutrition Therapy. In: Fauci AS, Kasper DL, Jameson JL, Longo DL, Hauser SL, eds. Harrison's Principles of Internal Medicine. 18th ed. New York: McGraw-Hill; Accessed February 8, 2013.
Drescher T, Singler K, et al. Comparison of two malnutrition risk screening methods (MNA and NRS 2002) and their association with markers of protein malnutrition in geriatric hospitalized patients. European Journal of Clinical Nutrition ; 64:
Karen L. Nestle Nutrition Insitute. The Elderly: Nutritional Needs, Challenges, Screening, and Solutions. May 2012 Webinar.
Morley JE. Undernutrition in older adults. Family Practice. 2012; 29: i89-i93. Doi: /fampra/cmr054.
National Academy of Sciences. Institute of Medicine. Food and Nutrition Board. Dietary Reference Intakes: Recommended Intakes for Individuals