1. UNINTENTIONAL WEIGHT LOSS in the ELDERLY Module 1
My name is __________ with the _________. I welcome you to the “Unintentional Weight Loss in the Elderly.” in the elderly or what some refer to as Failure to Thrive (FTT)
Ed Vandenberg, MD, CMD
Geriatric Section OVAMC
&
Section of Geriatrics
UNMC
Omaha, NE
Web: geriatrics.unmc.edu

2. PROCESS Series of 3 modules and questions on Etiologies and Evaluation
Step #1 Power Point module with voice overlay
Step #2 Case-based question and answer
Step # 3 Proceed to additional modules or take a break
Our process will be for you to complete a series of 3 modules and questions on the topics Etiologies and Evaluation of Unintentional Weight Loss in the Elderly. These modules will utilize power point with voice overlay. Each module will be followed by case based questions with answers that will explain the right and wrong responses. Then you will have the option to continue with the next module or take a break at that time. The learner is recommended to complete a module before disengaging. When the module and questions are completed click on “Mark Reviewed” on the main page of the minifellowship to indicate your completion.

3. Objectives All of Three Modules
The learner will be able to:
 identify indications for evaluation of weight loss
list age related changes that influence appetite
list the risk and benefits of appetite stimulants
Describe the evaluation of unintentional weight loss.
The objectives of our three modules are to assist you with identification of indications for evaluation of weight loss and the age related changes that influence appetite. We’ll review some of the appetite stimulants and then, finally, we’ll describe the evaluation of unintentional weight loss in the elderly.

4. OBJECTIVES of MODULE 1 The learner will be able to:
 identify indications for evaluation of weight loss
list age related changes that influence appetite
In this specific module, we will focus on indications for evaluation and age related changes that influence appetite. But first a bit of contemplation.

5. Senility Prayer God grant me the Senility to:
Forget the people I never liked anyway
The good fortune to run into the ones that I do
And
The good eyesight to tell the difference
God grant me the senility to forget the people I never liked anyway, the good fortune to run into the ones that I do, and the good eyesight to tell the difference.

6. DEFINITIONS Triggers for evaluation Wt. Loss:
>5% over 30 days or >10% over 180 d or
     intake < 75% of all meals for > 7 d
BMI < 20 (BMI = WT/ Ht squared) or
Albumin < 3.2
Remember the: “ ” rule     
There are probably 4 main triggers that should evoke an evaluation of weight loss in elders. The strongest is a weight loss of 5% over 30 days or 10% over 180 days. This is the criteria that Medicare surveyors use in nursing homes to decide whether an elder is in nutritional jeopardy. Intake of < 75% of all meals for over 7 days is a weak one because often times the interpretation by staff of diminished food intake isn’t always that accurate. BMI < 20 has a fair amount of literature behind it for us to begin to worry, and certainly low albumin. I try to recall this by a “ ” rule: 5% at 30 days, 10% at 180 days, or BMI < 20. Any of these criteria, however, should make us consider whether our elder is at nutritional risk and whether we should act.

7. INCIDENCE : Community-dwelling 5-20% [i]
Hospital admissions % [ii]
During hospital care % [iii]
Nursing Home % [iv]
Home health patients %
i] Irving GF, Olsson BA, Cederholm T. Gerontology 1999;45: [ii] Persson MD, Brismar KE, et. al.. JAGS 50: , Dec 2002 [iii) Veterans Affairs Total Parenteral Nutrition Cooperative Study Group. NEJM 191;325: [iv] Silver AJ, Morley JE, Strome LS et. al. JAGS 1998;36:
Peter D April
It’s not difficult to find nutritional impairment in the elderly.
Community dwelling: up to 20%
Hospital admissions: up to 60%
During hospital care: we may add an additional 25%
Nursing home: up to 54%
Home health patients: around 40%

8. NURSING HOME INCIDENCE of NUTRITIONAL MARKERS Nutritional markers
Weight loss >5% in 30 days or >10% in 180 days
10% of NH residents[i]
Albumin < 3.5 g/dl
6%-43% NH residents[ii], [iii]
99% of hospitalized NH residents[iv]
If we look at just our nursing home population, we’ll find that generally about 10% of the residents will meet that criteria of 5% in 30 days or 10% in 180 days, which is really a more severe marker of nutritional impairment than we saw on the previous slide. Similarly, albumin suppression is up to 43% of nursing home residents and virtually universal in the hospitalized nursing home residents. This data reinforces our need to be very vigilant in our nursing home patients for any type of nutritional problem and to be proactive.
[i] Blaum CS, Fries BE, et al. Factors associate with low body mass index and weigh loss in nursing home residents. J Gerontl A Biol Sci Med Sci 1995;50:M162-M168
[ii] Rudman D, Feller AG, et. al. Relation of serum albumin concentration to death rate in nursing home men JPEN J Parenter Enteral Nutr 1987;11:
[iii] Mantero-Atienzo E, Beach RS, et al. Nutritional status of institutionalized elderly in South Florida Arch Latinoam Nutr 1992;42:
[iv] Fergusion RP, O’Connor P. et. al. Serum albumin and prealbumin as predictors of clinical outcomes of hospitalized elderly nursing home residents JAGS 1993;412:

9. MORTALITY: BMI (Body Mass Index) Increase risk of death with :
MALES FEMALES
Begins: < < 22  
Significant: < < 20
Severe: < <18.5
Calle EE, Thun MJ, Petrilli JM et al. NEJM 1999;341:
BMI is an extremely useful parameter partly due to the research that’s been done. What we know is that in elders below 23 and 22 is the beginning of some mortality risk increase, but the risk really begins below 20. If your patient is below 18.5, they are in severe nutritional jeopardy and we would need at that point to do all we can to reverse that. We’ll review what to do in this module and future modules.

10. APPETITE and AGING Intake: Appetite: Declines with age
-Elders reset their
appetostat” down
-Average body wt, decreases after age: y.o.
-Eating alone associated with decreased dietary intake [i]
-Chronic pain associated with self reported appetite impairment [ii]
[i] De Castro JM Neurosci Biobehav Rev 1996;20:
[ii] Bosley BN, Weiner DK, et al. JAGS 52: , 2004
Intake:
18% community elders consume < 1000 kcal/day
40% of home health patients are malnourished [i]
10-20% elderly……… consume protein < RDA
10-30% of elders have subnormal levels of vitamins and minerals
Thomas DR, GRECC VA Medical Center St Louis Mo. Supplement to Annals of LTC 2002
Roberts SB, Fuss P. Heyman NF et. al. J Gerontl A Biol Sci Med Sci 1996;51:B158-B166
There is no question that we will begin to lose weight as we enter old age. There is some literature to support that we do not have the hunger drive or the “appetostat” to push us to eat as when we were younger. This “appetostat” does not increase nor are we able to turn it up during stress to improve our feeding. Literature supports that our weight declines after age 75. We know that some of the contributing factors - beyond just our physiology – are that many of these elders eat alone, which decreases dietary intake, or are experiencing chronic pain, which also suppresses the drive to eat. We see that 18% of elders consume < 1000 kcal a day. I mentioned earlier that up to 40% of home health patients are malnourished. Up to 20% of elders will consume less than the recommended daily allowance of protein and that up to 30% are below the RDA of vitamins and minerals. We’ll see later how critical these factors are in unintentional weight loss in the elderly

11. Caloric Needs. Changes with Aging Johnson LE
Caloric Needs Changes with Aging Johnson LE. Geriatrics in Review syllabus 4 th edition pp
Age
Calories (kcal/day
Protein (gm/kg/d)
Fat
Fiber
(g/day)
23-34
2700
0.8
< 30 %
20-35
65-80
1800 – 2100
1.0 – 1.25
< 30 %
Let’s compare elders to younger people. As you go across the chart it becomes clear that younger people need more calories per day. What is not known is that elders actually need more protein per kg than younger people, and that’s a surprise. Fats and fiber remain about the same. Why these changes? Let’s see the next slide.

12. CALORIC Need DECREASES WHY THE CHANGE?
Decreased metabolically active skeletal muscle
(accounts for 1/3 of the decline)
~45% of body wt in young adults is muscle
~27% of body wt in 70 y.o. is muscle
Johnson LE. Geriatrics in Review syllabus 4 th edition pp
Decreased physical activity
(accounts for 2/3 of the decline)
First of all, in the caloric department we have less metabolically active tissue - that’s skeletal muscle. This accounts for approximately one third of the decline in caloric need as we age. Let’s look at this muscle loss, when we were young adults about 45% of our body weight was muscle. As we age. after around 70 - this drops into the high 20% range and so we have less metabolically active muscle that we need to feed. We also become less active. This probably accounts for almost two thirds of the decline in what we need for calories.

13. PROTEINS Changes with age
FACTS:
Protein requirements increase with age
Low calorie diets require more protein than high calorie diets to achieve positive nitrogen balance
Albumin declines with disease
Jensen GL, Powers JS. Geriatric Review Syllabus 5th edition pp
Ling PR Schwartz JH Bistrian BR,. Am J Physiol 1997;272:E333-E339
FACTS:
No relationship between high protein intake and:
impairment of creatinine clearance
(Baltimore Longitudinal Study) or
osteoporosis (despite increased calcium excretion)
Albumin influenced by a variety of factors (cytokine mediated decline) via injury, disease or inflammatory conditions
As I mentioned earlier protein requirements actually increase with age. Some of the problems are low caloric intake that actually forces the body to require higher amounts of protein to get the elder into positive nitrogen balance. Then along comes disease that attacks our albumin, and this is influenced by cytokine mediated decline that comes from injury, disease or chronic inflammatory conditions. There was some concern that higher protein intake in elders will cause problems. Some of the things we do know is that it does not affect creatinine clearance nor does it have any effect on rate of development of osteoporosis. I put this is in just to reassure you that counseling your elders to increase their protein intake will not have a deleterious effect.

14. Estrogen cause decease appetite
Increase % body fat  increase leptin  increase BMR and decrease food intake
Testosterone increases leptin
Increase CCK causes decrease appetite, early satiation and decrease fat ingestions
Stomach decrease grehlin production which decreases hunger and increase fat utilization CART is an anorectic peptide in the hypothalamus
Let’s review the physiologic changes of aging and disease related changes that lead to appetite suppression and anorexia. Let’s begin at the very top of the chart and we’ll proceed in clockwise fashion.
Taste and smell will decrease with age. We find that elders have less ability to sense bitter or sweet and their preference for salty foods goes down. In the younger years this would have been a benefit for the hypertensives, etc., but it actually begins to work against the elders as they seem to become super sensitive to any kind of salt and find those kinds of foods objectionable.
Moving to the right we find cytokines. As we age we have a natural increase in our chronic inflammatory proteins, including cytokines, and, of course, diseases as mentioned earlier of the inflammatory type or trauma will increase them as well. We find these have a centrally suppressing affect on the appetite centers in our brain.
Next is our stomach. As we age our stomach becomes more stiff and unable to relax with filling. We will experience an earlier antral stretch. This releases a negative feedback on the CNS that tells our brain that we are satiated and earlier inclination to quit eating. The duodenum releases Cholecystokinin, which we know also suppresses appetite and leads to early satiation and decrease inclination to ingest fat.
Let’s move over to the left hand side and start from the top. Many women won’t believe it, but the data says that after menopause the decline in estrogen leads to a decrease in appetite. As we get a greater percent of body weight as fat, the adipocytes, we will increase their production of leptin. Leptin then will increase our basal metabolic rate a little, but more effectively will decrease our interest in food intake. For the men a decrease in testosterone leads to the same increase in leptin and suppression of appetite, and also leads to a decrease in muscle mass, which then has a negative feedback on our willingness to eat.
The sum total of this is suppression of appetite, leading to anorexia and ultimatly to weight loss.

15. REGULATION of APPETITE Summary
COMBINATION of:
1)   Peripheral satiation
2)   Central feeding drive
MODULATED BY: Cytokine and Hormonal feedback
In summary, regulation of appetite is driven by an earlier peripheral satiation and decreased central feeding drive. A big modulator of the central feeding drive is through cytokines and/or hormonal feedback.

16. Nutritional Maintenance Requirements
“ " Rule
Protein: maintenance: 1.0 gm/kg/day
Calories:
resting: kcal/kg ideal body weight/day
activity: increase by 1.5
Water: resting (maintenance): 30.0 ml/kg/day.
Now I need to give you something that is really useful day to day, which is a little mnemonic to remember basic nutrition and fluid requirements. What I’m giving you is strictly for maintenance only. Recall that if you’re calculating deficits you’ll have to add additional factors. It’s the “ ” rule. It stands for protein 1 gm per kg per day. By the way, all of these are per day or 24 hours. Calories up to 30 kcal per kg ideal body weight per day. Certainly with activity you increase by 50%, and we’ll review later some disease states that also precipitate an increase. Lastly, fluids or water intake that we will need at rest for maintenance is 30 ml per kg per day. I find knowing these I can quickly calculate someone’s fluid needs and also can monitor my consultations by dietary, etc., for accuracy.

17. INCREASE IN METABOLIC DEMANDS with INJURY & ILLNESS
Surgery- minor 1.1
Infection---mild
Infection---moderate 1.4
Infection---severe 1.6
Cancer—therapy 1.3
AIDS
Pulmonary disease 1.3
Skeletal trauma 1.35
Wound healing
Long bone fracture
Severe trauma
Severe infection /multiple trauma
Multiple trauma on ventilator
Trauma on steroids
Sepsis
Let’s move on to what happens to the nutritional demands during disease or injury. These are all increases above maintenance triggered by various illnesses. Here you see some mild, moderate and severe infection with progressive increase to as high as 1.6 increase. Wound healing is at a similar level. Then you get into some big trouble on the right hand side where fractures and severe trauma progressively increase the need on up to our highest level, which surprises me as well, was sepsis, needing almost a doubling of the nutritional demand.

18. REVIEW
Malnutrition has a high prevalence and is a significant health factor in the elderly
Appetite declines with age
Caloric requirement declines but protein requirement increases
Let’s review. What we have established here is that malnutrition has a very high prevalence and is a significant health factor in the elderly. Appetite declines with age. Lastly, caloric requirements decline but protein requirements increase.
This completes our first module on UNINTENTIONAL WEIGHT LOSS in the ELDERLY , we have more to do but let’s review with a question and answer. To access the question, close out of this window, advance to question 2, answer the question and review the answer. Then, if you would like, please proceed to module 2 where we will begin the Evaluation of UNINTENTIONAL WEIGHT LOSS Q 225

19. Question
In older persons, decreased caloric intake is most likely caused by a decrease in which of the following?
A. Basal metabolic rate
B. Body weight
C. Lean body mass
D. Physical activity