1. NUTRITION AND WEIGHT Suggestions for Lecturer -1-1.5hour lecture
-Use GNRS slides alone or to supplement own teaching materials.
-Refer to GNRS for further content and for strength of evidence (SOE) levels.
-Refer to Geriatrics At Your Fingertips for updated information on patient evaluation and management.
-Supplement lecture with handouts.
-The GNRS Teaching Slides reflect care that can be provided to older adults in all settings. The words patient, resident, and older adult have been used interchangeably, as have the words provider, clinician, and primary care provider. Given the continually ongoing changes in health care today, some of the guidelines around reimbursement may have changed since publication.

2. Know and understand: OBJECTIVES
Age-related changes in nutritional health
How to screen for and assess nutritional status
Nutritional syndromes common in older adults
Nutritional Interventions for undernutrition
Cultural factors that influence nutritional care
Legal and ethical issues related to nutrition

3. TOPICS COVERED
Age-Related Changes
Nutrition Screening and Assessment
Nutrition Syndromes
Nutritional Interventions
Culturally Appropriate Nutritional Care
Legal and Ethical Issues

4. AGE-RELATED NUTRITIONAL CHANGES
Body composition
Energy requirements
Macronutrient needs
Micronutrient requirements
Fluid needs

5. CHANGES IN BODY COMPOSITION WITH AGE
 Bone mass, lean mass, water content
 Total body fat, commonly with  intra-abdominal fat stores
Volume of distribution of many medications changes as a result of these shifts
Creatinine-based determinations can overestimate renal clearance in older adults
Cannot generalize well-standardized nutrient requirements of young or middle-aged adults to older adults

6. ENERGY REQUIREMENTS OF OLDER ADULTS
Reduced basal metabolic rate (BMR) in older adults reflects loss of lean body mass, including muscle mass
BMR is the principal determinant of total energy expenditure
Estimation of energy needs based on body weight: 25 to 30 kcal/kg/day
Avoid overfeeding, while still meeting basal requirements
The Harris-Benedict or similar equations can be used to predict basal energy expenditure

7. MACRONUTRIENT NEEDS (1 of 2)
MyPlate (
United States Department of Agriculture site
Modified food pyramid
Website has content for various demographics, including older adults
Replacing Food Pyramid

8. MACRONUTRIENT NEEDS (2 of 3)
Food and Nutrition Board of the Institute of Medicine of the National Academies recommends a prudent diet consisting daily of:
Protein: 0.8 g/kg/day (1.5 g/kg/day under stress)
Fat: 20%–35% of total energy intake per day, with reduced cholesterol, saturated fat, and trans-fatty acids
Carbohydrate: 45%–65% of total energy intake per day, with complex carbohydrate as the preferred fiber source
Fiber: 30 g/day (men), 21 g/day (women)
May need to protein restrict with renal or hepatic disease

9. RECOMMENDED MICRONUTRIENTS FOR ADULTS ≥ 71 YEARS OLD (1 of 2)
Recommended Daily Allowance
Nutrient
Men Women
Calcium Magnesium
Vitamin D
Thiamine
Riboflavin
Niacin
Vitamin B6
Folate
Vitamin B12
1,000 mg
350 mg
10 mcg
1.0 mg
1.1 mg
12 mg
1.4 mg
320 mcg
2.0 mcg
1000 mg
265 mg
10 mcg
0.9 mg
11 mg
1.3 mg
320 mcg
1.0 mcg
See GNRS5 Table 29.1
SOURCES: Data from Standing Committee on the Scientific Evaluation of Dietary Reference Intakes, Food and Nutrition Board, Institute of Medicine, Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride. Washington, DC: National Academy Press; 1997; Standing Committee on the Scientific Evaluation of Dietary Reference Intakes, Institute of Medicine, Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline. Washington, DC: National Academy Press; 1998; Standing Committee on the Scientific Evaluation of Dietary Reference Intakes, Food and Nutrition Board, Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Beta Carotene, and Other Carotenoids. Washington, DC: National Academy Press; 2000; Standing Committee on the Scientific Evaluation of Dietary Reference Intakes, Food and Nutrition Board, Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc. Washington, DC: National Academy Press; 2001; Standing Committee on the Scientific Evaluation of Dietary Reference Intakes, Institute of Medicine, Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate. Washington, DC: National Academy Press; 2004; Dietary Reference Intakes for Calcium and Vitamin D (2011). Available at (accessed Sept 2016).
*Adequate intakes, not recommended dietary allowances.

10. RECOMMENDED MICRONUTRIENTS FOR ADULTS ≥ 71 YEARS OLD (2 of 2)
Recommended Daily Allowance
Nutrient
Men Women
Pantothenic acid
Vitamin A
Vitamin K
Iron
Zinc
Vitamin C
α-Tocopherol
Selenium
Potassium
5 mg*
625 mcg
90 mcg*
6 mg
9.4 mg
75 mg
12 mg
45 mcg
4,700 mg*
5 mg*
500 mcg
90 mcg*
5 mg
6.8 mg
60 mg
12 mg
45 mcg
4,700 mg*
See GNRS5 Table 29.1
SOURCES: Data from Standing Committee on the Scientific Evaluation of Dietary Reference Intakes, Food and Nutrition Board, Institute of Medicine, Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride. Washington, DC: National Academy Press; 1997; Standing Committee on the Scientific Evaluation of Dietary Reference Intakes, Institute of Medicine, Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline. Washington, DC: National Academy Press; 1998; Standing Committee on the Scientific Evaluation of Dietary Reference Intakes, Food and Nutrition Board, Dietary Reference Intakes for Vitamin C, Vitamin E, Selenium, and Beta Carotene, and Other Carotenoids. Washington, DC: National Academy Press; 2000; Standing Committee on the Scientific Evaluation of Dietary Reference Intakes, Food and Nutrition Board, Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc. Washington, DC: National Academy Press; 2001; Standing Committee on the Scientific Evaluation of Dietary Reference Intakes, Institute of Medicine, Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate. Washington, DC: National Academy Press; 2004; Dietary Reference Intakes for Calcium and Vitamin D (2011). Available at (accessed Sept 2016).
*Adequate intakes, not recommended dietary allowances.

11. FLUID NEEDS OF OLDER ADULTS
Normal aging is associated with:
Decreased perception of thirst
Decreased response to serum osmolarity
Reduced ability to concentrate urine following fluid deprivation
Fluid needs of older adults can be met with 30 ml/kg/day or 1 ml/kcal ingested
A decline in fluid intake can also result from disease states that reduce mental or physical ability to recognize or express thirst, or that result in decreased access to water
Fluid needs may increase during episodes of fever or infection, as well as with diuretic or laxative therapy.

12. Common signs of dehydration:
Dehydration is the most common fluid or electrolyte disturbance in older adults
Common signs of dehydration:
Decreased urine output
Constipation
Mucosal dryness
Confusion

13. NUTRITION SCREENING AND ASSESSMENT
Anthropometrics
Nutritional intake
Laboratory tests
Drug-nutrient interactions
Multi-item tools for Nutrition Screening

14. ANTHROPOMETRICS Includes measures of weight and height
Body mass index (BMI) = weight in kg/height in m2
Risk threshold for low BMI = 18.5 kg/m2
Should be interpreted in the context of the individual’s lifelong weight history
Weight loss of 5% in 1 month or 10% in 6 months indicates nutritional risk and morbidity and predicts:
Functional limitations
Health care charges
Need for hospitalization
Less practical for routine clinical use: skin fold and circumference measurements because of the difficulty of achieving acceptable reliability among those taking the measurements.

15. NUTRITIONAL INTAKE
Inadequate nutritional intake has been defined as average intake of food groups, nutrients, or energy 25% to 50% below a threshold level of the RDI
Poor intake is often an indication of illness
5% to 18% of nursing home residents do not meet standards for adequate nutritional intake
Problems with obtaining food commonly contribute to inadequate nutritional intakes among older adults
Important to ascertain whether limitations in resources, transportation, or functionality may limit access to food or the ability to prepare and/or consume food
RDI= Recommended Dietary Intake
In one study, energy intake (<50% of calculated maintenance energy requirements) was reduced in 21% of the population of hospitalized older adults. This subset of patients had higher rates of in-hospital mortality and 90-day mortality than did those with energy intakes above the threshold.

16. LABORATORY TESTS: ALBUMIN
A risk indicator for morbidity and mortality
Hypoalbuminemia - lacks sensitivity and specificity as a nutritional indicator
The prognostic value of low albumin (<3.5 g/dL) is probably as a marker for injury, disease, or inflammation
Prealbumin may better reflect short-term changes in protein status (because of shorter half-life) but has largely the same limitations as albumin
In the community setting, hypoalbuminemia has been associated with functional limitations, sarcopenia, increased health care use, and mortality (SOE=B). In the hospital setting, hypoalbuminemia has been associated with increased length of stay, complications, readmissions, and mortality (SOE=B).
In the presence of inflammation, neither albumin nor prealbumin are accurate predictors of malnutrition. However, prealbumin can be used to assess the effectiveness of nutritional interventions or as an indicator of recovery (SOE=B).

17. LABORATORY TESTS: SERUM CHOLESTEROL
Low cholesterol levels (<160 mg/dL) are often detected in individuals with serious underlying disease such as malignancy
Acquired hypocholesterolemia (<160 mg/dL) is a nonspecific feature of poor health status that is independent of nutrient or energy intake
May reflect a pro-inflammatory condition
Community-dwelling older adults with both low albumin and low cholesterol have higher rates of morbidity and mortality than those with either low albumin or low cholesterol alone
Poor clinical outcomes have been reported among hospitalized and institutionalized older adults with hypocholesterolemia.

18. DRUG-NUTRIENT INTERACTIONS (1 of 3)
Medications can modify the nutrient needs and metabolism of older adults
Certain medications, such as digoxin and phenytoin, even at therapeutic levels, can cause anorexia in older adults
Many medications are known to interfere with taste and smell, and others can reduce the availability of specific nutrients
Some medications can reduce intake by causing inattention, dysphagia, dysgeusia, or xerostomia
Medications that precipitate constipation can also reduce appetite
Many medications can also cause anorexia including: SSRIs, calcium channel blockers (eg, dihydropyridines), H2-receptor antagonists, proton-pump inhibitors, narcotic and nonsteroidal analgesics, furosemide, potassium supplements, ipratropium bromide, and theophylline

19. DRUG-NUTRIENT INTERACTIONS (2 of 3)
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
Colchicine Vitamin B12
Digoxin Zinc, total kcal
Diuretics Zinc, magnesium, vitamin B6, potassium, copper
Isoniazid Vitamin B6, niacin
Laxatives Calcium, vitamins A, B2, B12, D, E, K
Levodopa Vitamin B6

20. DRUG-NUTRIENT INTERACTIONS (3 of 3)
Reduced nutrient availability
Lipid-binding resins
Metformin
Mineral oil
Phenytoin
Salicylates
SSRIs
Theophylline
Trimethoprim
Vitamins A, D, E, K
Vitamin B12, total kcal
Vitamin D, folate
Vitamin C, folate
Total kcal (via anorexia)
Folate
SSRIs = selective serotonin-reuptake inhibitors

21. MULTI-ITEM TOOLS FOR NUTRITION SCREENING (1 of 2)
The Nutrition Screening Initiative:
Three interdisciplinary tools to screen for nutrition risk and help evaluate the nutritional status of older adults
DETERMINE checklist:
10 item, self-report questionnaire
Identifies risk but does not diagnose malnutrition
Level I screen, intended for use by health care professionals, incorporates additional assessment items regarding dietary habits, functional status, living environment, and weight change, as well as measures of height and weight
Level II screen, for use by more highly trained medical and nutrition professionals and suggested for use in the diagnosis of malnutrition
Nutritional screening tools for older adults have been widely disseminated. Their effectiveness remains to be demonstrated and, more specifically, whether these tools can identify undernourished individuals whose problems are amenable to intervention.
The Nutrition Screening Initiative is a collaborative effort of the American Dietetic Association, the American Academy of Family Practitioners, and the National Council on Aging, Inc.
DETERMINE checklist: Has 2 Levels: The Level I screen, intended for use by health care professionals, incorporates additional assessment items regarding dietary habits, functional status, living environment, and weight change, as well as measures of height and weight. The Level II screen, for use by more highly trained medical and nutrition professionals and suggested for use in the diagnosis of malnutrition, contains all the items from Level I with additional biochemical and anthropometric measures, as well as a more detailed evaluation of depression and mental status.
Simplified Nutrition Assessment Questionnaire can be answered by patients through the mail or while sitting in a waiting room; it has a sensitivity and specificity of 88.2% and 83.5% for identifying those at risk of weight loss

22. MULTI-ITEM TOOLS FOR NUTRITION SCREENING (2 of 2)
Mini-Nutritional Assessment:
18 items, requires administration by a trained professional, short form consists of 6 items
Evaluates the risk of malnutrition among frail older adults and to identify those who may benefit from early intervention
Simplified Nutrition Assessment Questionnaire:
Can be answered by patients through the mail or while sitting in a waiting room
Sensitivity and specificity of 88.2% and 83.5% for identifying those at risk of weight loss

23. RISK FACTORS FOR POOR NUTRITIONAL STATUS
Alcohol or substance abuse
Cognitive dysfunction
Decreased exercise
Depression, poor mental health
Functional limitations, limited mobility, transportation
Inadequate funds
Limited education
Medical problems, chronic diseases
Medications
Poor dentition
Restricted diet, poor eating habits
Social isolation

24. NUTRITION SYNDROMES: INVOLUNTARY WEIGHT LOSS (1 of 3)
~ 50% organ related (congestive heart failure, COPD, renal failure, chronic infection and inflammatory states, GI conditions, adverse medication effects, and neurodegenerative conditions)
20% neoplastic
20% idiopathic, including sarcopenia associated with aging
10% psychosocial conditions

25. NUTRITION SYNDROMES: INVOLUNTARY WEIGHT LOSS (2 of 3)
Clinically important weight loss is a loss of 10 lbs (4.5 kg) or >5% of usual body weight over a period of 6–12 months
A BMI <17 is consistent with under-nutrition
Excess loss of lean body mass is associated with poor wound healing, infections, pressure sores, depressed functional ability, and mortality
Involuntary weight loss is present in approximately 13% of older outpatients, 25%–50% hospitalized older adults, and >50% of nursing-home residents

26. NUTRITION SYNDROMES: INVOLUNTARY WEIGHT LOSS (3 of 3)
Evaluation should include:
Careful documentation of weights over time
Detailed history including medical, dietary, and psychosocial elements
Physical examination
Focused additional testing based on the history, physical, and limited standard laboratory profile
Institution of treatment of underlying cause
Appropriate follow-up to assess response to management
Nutritional therapy should include: Dietary education, removing dietary restrictions for chronic conditions, nutritional supplements given between meals and a multivitamin/multimineral supplement

27. NUTRITION SYNDROMES: OBESITY
Defined as a BMI  30 kg/m2
Associated with hypertension, diabetes mellitus, cardiovascular disease, obstructive sleep apnea, and osteoarthritis
Adverse outcomes include impaired functional status, increased health care resource use, and increased mortality
Prevalence has increased in all age groups, both genders, and all racial and ethnic groups
A BMI ≥35 kg/m2 is associated with increased risk of functional decline among older adults.
In older individuals, higher BMI may have a protective effect with mortality rates lowest for individuals with BMIs between 27 and 29. This effect may be related to lean body mass, because muscle mass is inversely associated with mortality risk in older adults independent of fat mass and cardiovascular and metabolic risk factors.

28. TREATMENT OF OBESITY
Goal: To achieve a more healthful weight to promote improved health, function and quality of life
Use a combination of prudent diet, behavior modification, and physical activity
For frail, obese older adults, emphasize preservation of strength and flexibility rather than weight reduction
From the NIH, “Age alone should not preclude weight loss treatment for older adults. A careful evaluation of potential risks and benefits in the individual patient should guide management.”
NIH = National Institutes of Health

29. NUTRITIONAL INTERVENTIONS: ORAL NUTRITION
Preventing undernutrition is much easier than treating it
Enhance food intake by:
Catering to food preferences as much as possible
Avoiding therapeutic diets unless their clinical value is certain
Placing two or more patients together for meals can increase sociability and food intake
Preparing foods with appropriate consistency, attention to color, texture, temperature, and arrangement.
Using herbs, spices, and hot foods helps to compensate for loss of the sense of taste and smell and avoiding the excessive use of salt and sugar
Avoiding hard-to-open individual packages
Giving adequate time for leisurely meals
Patients should have appropriate hand and mouth care, and they should be comfortably situated for eating. Assistance should be provided for those who need help
Title IIIC of the Older Americans Act has provided for congregate and home-delivered meals for older adults, regardless of economic status. This service is available in most parts of the country, albeit with a waiting list in many locations. Adequate access to nutritious and appetizing food should be assured for patients of various cultural backgrounds and in all settings.

30. NUTRITIONAL INTERVENTIONS: NUTRITIONAL SUPPLEMENTS (1 of 2)
Often decrease food intake, but overall nutritional intake increases due to nutrient quality and supplement density
Contain macro- and micronutrients
Available in liquid and bar forms
Chosen based on patient preferences, chewing ability, or product cost
Most formulas provide 1–1.5 calories/mL, and many are lactose- and gluten-free
There is no evidence of improvement in functional benefit or reduction in length of hospital stay with supplements. In addition, current evidence does not support routine supplementation for older people at home or for well-nourished older patients in any setting.

31. NUTRITIONAL INTERVENTIONS: NUTRITIONAL SUPPLEMENTS (2 of 2)
Use of micronutrient supplements is growing, approximately 60% of older adults take self-prescribed dietary supplements
Many vitamin and mineral supplements are commonly available in supermarkets and drugstores and are generally safe except for excessive intake of some such as vitamins A, D, and iron
There is poor to insufficient data that many nutritional supplements are beneficial
Imperative that the clinician obtain information about the patient’s use of all supplements
There is no evidence of improvement in functional benefit or reduction in length of hospital stay with supplements. In addition, current evidence does not support routine supplementation for older people at home or for well-nourished older patients in any setting.

32. VITAMIN D DEFICIENCY Occurs in 30% of individuals >70 years old
Associated with impaired calcium absorption and reduced physical activity level
Screen for vitamin D deficiency with measurement of total vitamin D levels
Supplements of vitamin D up to 4,000 IU (100 mcg) daily are considered safe
Repletion is associated with improved physical performance, reduced falls, improved bone healing, and response to bisphosphonates

33. DRUG TREATMENT FOR UNDERNUTRITION SYNDROMES
No reports demonstrating improvement in long-term survival, may cause serious adverse effects
Adverse effects associated with medications (most used off-label) used for treatment:
Mirtazipine: Caution with doses >15 mg/d due to hepatic and renal insufficiency
Cyproheptadine: Can cause confusion
Megestrol: On Beers List. Increased risk of DVT, fluid retention, edema, and CHF exacerbation. May negate effects of exercise on strength and function
Dronabinol: Somnolence and dysphoria
Human Growth Hormone: Contraindicated in cancer states. Hyperglycemia and fluid retention
Anabolic Steroids: no significant improvement in strength, function, or a reduction in fractures
DVT = Deep-Vein Thrombosis
CHF = Congestive Heart Failure
Mirtazapine (used off-label): Caution is required for dosages of 15–30 mg/d because of hepatic or renal insufficiency and more noradrenergic and serotonin effects, some of which may counteract the appetite stimulatory effects.
CyproheptadineOL, a serotonin and histamine antagonist, can also enhance appetite (SOE=C), but there is the potential for confusion in older adults.
Appetite and weight usually improve with megestrol acetate; however, this weight gain is primarily fat, and clinical benefits have not been demonstrated (SOE=A). In addition, megestrol acetate in nursing-home populations can be associated with a higher risk of deep-vein thrombosis, fluid retention, edema, and exacerbation of congestive heart failure. There is a strong Beers List warning to avoid prescribing this agent. Finally, megestrol acetate taken during rehabilitation may negate the benefits of exercise on strength and function.
DronabinolOL, a cannabinoid, can stimulate appetite at 2.5 mg twice daily before lunch and dinner (maximum 20 mg/d), but it is associated with somnolence and dysphoria in older adults.
Anabolic agents include human growth hormoneOL, which induces preferential usage of carbohydrates and fats while preserving proteins and increasing muscle mass. However, increased muscle strength and functional capacity, depend on exercise rehabilitation. Oxandrolone is an anabolic steroid that increases muscle protein synthesis; it is given at 2.5–20 mg/d po in divided doses. Anabolic agents can increase muscle mass, but questions remain concerning long-term safety and cost that currently mitigate endorsement (SOE=B). Likewise, although muscle mass has consistently improved with anabolic agents, significant improvements in strength and function, or a reduction in fractures have not been demonstrated.

34. CULTURALLY APPROPRIATE NUTRITIONAL CARE
Ethnic and religious customs are two of many factors that influence food preferences
Nutrition and aging are connected inseparably, because eating patterns affect progress of many chronic and degenerative diseases associated with aging
Culturally appropriate nutrition education materials:
MyPlate for Older Adults: Available in English and Spanish
Oldways®: Promotes healthy eating based on regional diets, has consumer-friendly pyramids that display food choices in a culturally sensitive manner
For example, many Latinos believe in disease as destiny (ie, fatalism) and often fear adverse effects of medications given to treat disease. Some patients expect the healer to cure the ailment, with difficulty comprehending the concept of chronic illness. This can greatly compromise the care of certain conditions such as diabetes. The hot and cold theory of disease traditionally held by Hispanic cultures is a continuing influence of ancient Greek and Arabic humoral pathology, which maintained that the four body “humors” regulated health and disease: blood, bile, and black and yellow bile, each characterized as warm or cold, wet or dry. Although disagreement exists within Latino populations, warm illnesses (kidney ailments, rashes, dysentery) are produced by the body, and cold illnesses (pain, paralysis, stomachache) are produced by outside influences. Warm illnesses are treated by avoiding cold foods (vegetables, dairy products, tropical fruits), and cold illnesses by avoiding warm foods (lamb, beef, grains, temperate fruits).

35. LEGAL AND ETHICAL ISSUES
Food and fluids should always be offered to all patients
The decision to start or to discontinue artificial nutrition or hydration must be considered very carefully
Competent adults may choose to forgo artificial feeding, just as they have the right to decline any invasive procedure
Advance directives should be honored unless there is compelling evidence that the individual would have changed his or her mind in the current

36. LEGAL AND ETHICAL ISSUES
In incompetent adults without advance directives the decision to start or to discontinue artificial feeding should be considered carefully with the surrogate
Take into account the risks and burdens of such an action, the risks and burdens of alternative actions, and the evidence to support likely benefits of the various actions
Current evidence does not support the use of feeding tubes in patients with end-stage cancer, dementia, or COPD
Palliative care, including emotional support, is extremely important at the end of life

37. SUMMARY
Nutritional concerns affect many aspects of health and disease in older adults
Acceptable parameters of nutritional status such as body weight and protein levels should be maintained, unless the patient’s clinical condition demonstrates that this is not possible
There are many tools to help screen and assess for nutritional deficiencies
Cultural factors play a role in nutrition intake
The decision to start or discontinue artificial nutrition or hydration must be considered very carefully

38. CASE (1 of 4)
An 81-year-old woman is admitted to a nursing home after 6 weeks in hospital for pneumonia and acute respiratory failure. She is deconditioned and needs assistance with all ADLs.
Hospital course
Intubation and ventilatory support for 3 days
Complications: acute kidney injury requiring dialysis, prolonged ileus, pressure ulcers, UTI, C. difficile–induced colitis, mild right-hemisphere stroke
At discharge, all catheters, IV lines, and antibiotics were discontinued.
She can ambulate short distances.
She tolerates a regular diet.
No difficulty chewing or swallowing, per recent assessments by dietitian and speech therapist

39. CASE (2 of 4) Physical examination (at nursing home)
Vital signs, chest, cardiac, and abdominal findings: unremarkable
Weight 82 kg (181 lb) (pre-hospitalization: 81.5 kg)
Pretibial and presacral edema 3–4+
Unstageable 5 cm × 4 cm sacral pressure ulcer surrounded by non-inflamed, healthy skin
Muscle strength: mild weakness of left upper extremity
Laboratory findings
Hemoglobin 10.5 g/dL
WBC 7.8/µL
Creatinine 1.8 mg/dL
BUN 12 mg/dL
Albumin 2.7 g/dL

40. CASE (3 of 4)
Which one of the following is most appropriate for optimizing the patient’s nutritional status?
Start megestrol acetate, 400 mg orally twice each day.
Order a complete swallowing assessment.
Place a feeding tube and start enteral feedings with a high-protein polymeric (nutritionally complete) formula at a rate sufficient to provide 30 kcal/kg daily.
Provide feeding assistance and monitor nutrient intake with complete calorie counts for the next 3 days.
Start a high-protein oral nutritional supplement, 240 mL three times daily between meals.

41. CASE (4 of 4)
Which one of the following is most appropriate for optimizing the patient’s nutritional status?
Start megestrol acetate, 400 mg orally twice each day.
Order a complete swallowing assessment.
Place a feeding tube and start enteral feedings with a high-protein polymeric (nutritionally complete) formula at a rate sufficient to provide 30 kcal/kg daily.
Provide feeding assistance and monitor nutrient intake with complete calorie counts for the next 3 days.
Start a high-protein oral nutritional supplement, 240 mL three times daily between meals.
ANSWER: D
This patient has likely been in a profound catabolic state throughout most of her hospital stay and is now at high nutritional risk. Although her weight has dropped only 1 kg (2.2 lb) since admission, she has extensive edema that is masking a much more profound loss of body mass. Improving her nutritional status is of prime importance. Her medical condition appears to be stabilizing and she is tolerating a regular diet, with no apparent chewing or swallowing problems. No information is given as to the total amount of nutrients or the protein, energy, or micronutrient composition of the food she is consuming. This information is needed to determine whether her current nutrient intake is optimal, and before a decision as to whether other forms of nutrition support are advisable. The patient’s nutritional needs and preferences should be assessed carefully, her diet optimized, and any need for feeding assistance addressed. An interprofessional team is required to provide optimal nutritional care.
The use of oral nutrition supplements is controversial and should not be the first recourse. The supplements are effective in increasing weight in older patients, yet there is less certainty as to whether supplements improve clinical outcomes, and no prospective studies have compared supplements or tube feeding with enhanced bedside care (SOE=A). This is an important issue, because studies have shown that focusing on the quality, timing, and frequency of meals can significantly improve an older patient’s total nutrient intake (SOE=B). The focus can include working with a dietitian to ensure that the patient’s dietary preferences are addressed, food consistency is modified to minimize chewing or swallowing problems, energy- and protein-dense foods are provided, and benefits of between-meal snacks are assessed. Adding variety to the menu and attention to packaging, food color, texture, temperature, and flavor enhance food intake (SOE=C). Restrictive therapeutic diets should not be used when oral intake is inadequate unless there is a strong clinical indication (SOE=C). Studies have shown that simple measures can lead to a 35%–40% increase in older patients’ energy intake. For example, adding between-meal snacks has been shown to increase daily intake by 600 kcal and 12 g protein and was associated with shorter lengths of stay among hospitalized patients (SOE=B).
Megestrol acetate would not be a good choice for this patient. Although its use is associated with an increase in weight and appetite in some patient populations, there is considerable controversy as to the composition of the weight gain, no evidence of benefit regarding other clinical outcomes, and a high risk of serious adverse effects when given to frail older adults (SOE=A). Probably as a result of its strong corticosteroid agonist properties, megestrol acetate, at a dose of 800 mg/d, negates the benefits of exercise on strength and function in older patients in recuperative care (SOE=B). Its use in nursing homes is also associated with a higher risk of deep-vein thrombosis, fluid retention, edema, and exacerbation of heart failure (SOE=B). Use of megestrol acetate should be considered only after all other nutritional interventions have failed.
Because recent assessments by a dietitian and a speech therapist suggested no problems, a formal swallowing study is not indicated. Should repeat bedside assessment or subsequent monitoring suggest a swallowing problem, formal assessment can be reconsidered. Placement of a feeding tube should be considered if there is clear documentation that volitional oral intake is inadequate despite optimal nutritional care. There is no evidence that tube feeding improves clinical outcomes of recuperating patients with a normally functioning gastrointestinal tract, and there is considerable evidence of potential harm (SOE=A).

42. GNRS5 Teaching Slides Editor:
Barbara Resnick, PhD, CRNP, FAAN, FAANP, AGSF
GNRS5 Teaching Slides modified from GRS9 Teaching Slides
based on chapter by James S. Powers, MD, AGSF
and Maciej S. Buchowski, PhD
and questions by Dennis Sullivan, MD
Managing Editor: Andrea N. Sherman, MS
Copyright © 2016 American Geriatrics Society