1. UNINTENTIONAL WEIGHT LOSS EVALUATION in the ELDERLY Module 2
Welcome to Module 2 of “Evaluation of Unintentional Weight Loss in the Elderly.” Hi, my name is ____________. If you have not completed module one of this series, please close out of this module and do module one and they return here.
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. If you have not completed the first module, please do so at this time and then return to this module.
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. When the module and questions are completed click on “Mark Reviewed on the main page of the minifellowship to indicate your completion.

3. Objectives The learner will be able to:
list the risk and benefits of appetite stimulants
Describe the evaluation of unintentional weight loss.
In this specific module we will focus on both the evaluation of weight loss and some of the tools we might use to stimulate appetite.

4. This large algorithm overview was originally proposed by John Morley and Dave Thomas, and I think it really helps us to organize in our evaluation. I will briefly review this and then go into more in depth as we progress through the module.
In the top box we see the indications for evaluation we studied in the earlier module. Some of the things that the clinician needs to decide on their first evaluation are right there: delirium, dehydration, is the patient under eating or eating adequately, are they depressed, do they have dysphagia, and then one needs to harness the nutritional support to assist them.
Lastly, then we will begin our evaluations for other etiologies, as we see in the box labeled “Search for Treatable Causes - Meals on Wheels.” Let’s proceed and begin to dissect this project.

5. WEIGHT LOSS EVALUATION algorhtym
Triggers
5% in 30 days or 10% in 180 days ……….or
Intake < 75 % for > 7 day………………….or
BMI < 20…………………………………or
Albumin < 3.2
Delirium ?
After we determine that our patient is at significant risk nutritionally ( as defined in the top box) , we need to assess them quickly and find out if delirium is a factor. If we don’t treat that problem we will never get anywhere. And of course we would want to correct any dehydration.
Dehydration ?

6. Anorexia? Depressed ?? Dysphagia ?
Yes
Depressed ??
Treat
Dysphagia ?
Yes
Speech Therapy
We must decide quickly if our patient is anorectic or are they eating adequately and just metabolically burning it up. Far and away the large proportion will always be anorectic. We can do a quick assessment by the “ ” rule. That is are they taking in Protein 1 gm/kg/day and Calories 30 Kcal/kg/day and Fluid 30 cc/kg/day. Usually we should always involve a dietitian to not only assess the caloric needs, but also to begin formulating a plan to replete them as we see at the bottom of the slide.
We don’t wish to stop there, however. We need to assess for depression. Depression is a common contributor to anorexia. We need to scrutinize very carefully for depression and treat it. Despite what we’ve found already, dysphagia needs to be screened for also with careful questioning of the patient and/or family about swallowing and chewing problems. If we get answers that imply “no problems”, we shouldn’t stop there but should pursue a little bit further to find out if there are foods that they do not eat anymore because they have swallowing problems. Often with this question we will “dig up” some pertinent positives. With any swallowing abnormality we would recommend the evaluation begin with speech therapy. Speech therapy can then guide them through the remainder of the workup to give us a good consultation. Lastly, before the patient gets out of our clutches, and as we already mentioned, a dietary evaluation to get them started on oral supplements to bridge them over until we get things turned around. What about appetite stimulants? Where do they fit? No
Dietary Evaluation
Oral Supplements
Appetite Stimulants?
Next page

7. When & how to choose appetite stimulants?
Will patient want it?
What beneficial side effects can I utilize?
Do the negative side effects outweigh the beneficial?
We’re going to cover appetite stimulants a little bit. As their clinician, some of the questions we want to ask are:
Will the patient want it?
What are some of the beneficial side effects of the medications that I can utilize as well?
Do any of their negative side effects outweigh the beneficial?

8. Appetite Stimulants Adapted from: Appetite and orexigenic drugs
Appetite Stimulants Adapted from: Appetite and orexigenic drugs. Morley, Thomas
Drug
Dose
Additional benefits
Mechanism of Action
Megestrol
(Megace)
400 mg (start) mg q day
Progestagen & anticytokine
mirtazapine
(Remeron)
7.5 mg (start) mg q hs
antidepressant & sleep
Histamine and seratonin
trazadone
25 mg (start) mg q hs
sleep
Seratonin
Probably the most commonly used medication is Megace or Megestrol. The starting dose is usually 400 mg; the mechanism of action is blocking the suppression effect of the cytokines on the central appetite regulators. Side effects: probably the most common and worrisome is DVT. Megace probably has its best role in conditions of high level of chronic inflammatory proteins, such as cancers, autoimmune diseases, and chronic infectious states. Note; Megestrol, mirtazapine and trazadone have not received approval for appetite stimulation alone.
Next is mirtazapine - trade name Remeron. This is a unique antidepressant. At low doses of mg you get not only the antidepressant effect to some degree, but also the additional benefit of sleep as well as the appetite stimulant. These lower dose responses are mediated predominantly through histamine.
Lastly, trazadone is a very weak antidepressant but a good sleep agent, and it may also benefit appetite to a small degree.

9. Appetite Stimulants Adapted from: Appetite and orexigenic drugs
Appetite Stimulants Adapted from: Appetite and orexigenic drugs. Morley, Thomas
Drug
Dose
Additional benefits
Mechanism of Action
dexamethasone
4 -10 mg per day
anti-inflammatory
central
Dronabinol(Marinol)
2.5 mg q hs, change to pre-supper if tol. Add 2.5 mg pre-evenig meal as needed
anti-anxiety, anti-nausea
Cannabinoid
(central)
Metaclopro-mide
(Reglan)
5mg (start)-10 mg q 6 hrs
gastric emptying,
anti-nausea
gastric emptying
We know dexamethasone can be a powerful appetite stimulant albeit short lived. It is mediated primarily centrally and its anti-inflammatory effect is an additional benefit.
An interesting drug is dronabinol or trade name Marinol. In most of the literature it’s been used in chemotherapy induced nausea–anorexia or in the agitated demented. Here it’s additional benefit has been both to reduce anxiety and nausea. It’s mediated predominantly centrally. In the agitated demented or frail elder it’s best to start at 2.5 mg at hs to get a feel for its sedative potential. Once you see it’s tolerated you can move it up to right before the pre-supper time and add additional doses but probably never more than 5 mg a day.
Lastly, we have Metaclopromide or Reglan although it’s centrally acting effect is mediated through dopamine. Here its effect on improving eating is predominantly through gastric emptying and improving gastric stretch. Patients that benefit most are those who have been eating minimally and are now trying to increase,and then have early satiety and nausea and can’t seem to eat more despite their best attempts. A small dose before each meal 2.5 – 5 mg can improve their ability to eat and consume. Reglan, of course, is not ideal for long term use because of its extra-pyramidal side effect and should be discontinued once the patient is progressing. Metaclopromide and dexamethasone do not have FDA approval for appetite stimulation alone.

10. Appetite Stimulants Adapted from: Appetite and orexigenic drugs
Appetite Stimulants Adapted from: Appetite and orexigenic drugs. Morley, Thomas
Drug
Dose
Additional benefits
Mechanism of Action
testosterone
200mg IM q 2 wks
hypoandrogenism
anabolic
oxandrolone
2.5 mg (start) bid-- max 20 mg /day-for 2-4 weeks
An additional way to stimulate appetite and weight gain is through hormone manipulation. Sarcopenia and poor appetite may be a sign of hypogonadisml. Here it’s recommended to measure a free testosterone or, even better, a bioavailable testosterone. If low proceed to check PSA to screen for prostate cancer and if it is within the normal range then on can begin testosterone replacement. Incidentally, osteoporosis in a male is another indication to check testosterone . Small case controlled studies of testosterone supplement in older men of up to 3 years duration reported improvements in muscle strength, lean body mass, bone mass, cognitive function and sense of well being. You should monitor for adverse effects of polycythemia and exacerbation of prostatic disease during treatment.
Oxandrolone, an anabolic steroid, is considered for females who also show sarcopenia and anorexia. It,s mechanism of action is similar to testosterone in the form of its effect as an anabolic agent. It’s suggested to start 2.5 mg twice a day, maximum is 20 mg a day. Maximum length of time of use is approximately 2 months. So this can serve as a “jump start” for your elders who are failing.

11. PHARMACOLOGICAL AGENTS for UNITENTIONAL WEIGHT LOSS
IMPROVED WEIGHT
AGENT CONDITION APPETITE GAIN
Corticosteroids
Cancer
Yes No
AIDS
Cyproheptadine
Cannabinoids (Marinol,dronabinol) NO
Cannabinoids (dronabinol)
Dronabinol plus megestrol acetate
Thalidomide
----
Recombinant growth factor
-----
Weight loss in LTC
Oxymetholone
Hydralazine sulfate
Megestrol acetate
Megestrol acetate & prednisolone
Dialysis
Megestrol acetate vs. cyproheptadine
Weight loss in LTC
Alzheimer’s disease
Here’s a very long slide that you may wish to return to later. It outlines the areas where pharmacologic agents have been used as appetite stimulants based on certain conditions and it outlines their effectiveness. A couple points to make is that Cyproheptadine has anticholinergic effects, which can certainly be formidable ad prohibit it’s use. Recombiant growth factor is obviously being worked on but is not yet in the realm of use. Down toward the bottom you see a longer list on Megace or Megestrol, which is used in cancer, AIDS, weight loss in long term care. ]
For references see original article by Morley JE, Evans WJ et al. Anorexia in the Elderly: An Update.
Nutrition Literature Resource Compendium Supplement to Annals of Long Term Care. 2001

12. Search for treatable causes
“MEALS OF WHEELS”
If you recall where we are at on the algorithm ( seen on the left) and that by now we should have looked at delirium, dehydration, dysphagia, and depression, and started dietary interventions and considered whether or not to add appetite stimulants, then it’s time to also launch our workup for treatable causes. The Meals on Wheel mnemonic of Thomas and Morley really helps us to think “outside the box” on this issues.
Often the evaluation focuses on cancers and medical problems only . This mnemonic helps us to think more globally. We make two mistakes commonly in the evaluation of the elderly; NOT THINKING MULTI FACTOIALLY and THINKING ONLY PATHOPHYSIOLOGY AS OPPOSED TO MORE GLOBALLY AND INCLUDING SOCIAL PSYCHOLOGICAL FACTORS AS WELL. The mnemonic help us us to avoid this error. Please permit me to use this mnemonic to work on this problem further with you. I will use it as a template to discuss further evaluation of loss of weight.

13. Search for Treatable causes “MEALS ON WHEELS” MNEMONIC
M edications/Medical
E motional problems
A lcoholism / A buse / A cid
(stomach)
L ate life paranoia
S wallowing problems
O ral problems
N o money (poverty)
W andering and other dementia-related behaviors
H yperthyroidism / H yperparathyroidism
E ating problems (tremor, stroke, etc.)
E nteric problems (e.g. constipation, Cancer, etc.)
L ow salt diet, other therapeutic unpalatable diets
S hopping problems
/ S ocial isolation
“Meals on Wheels” as laid out here is a very effective reminder of how to look for treatable causes that aren’t always medical. We will quickly review each topic and then go into more depth through the remaining slides. Starting on the upper left corner, certainly medical problems always come to mind as causes of weight loss. However, medications don’t always and we’ll review those. I already mentioned emotional problems. The A’s conjure up alcoholism, abuse and stomach acid or gastritis. Paranoid states can occur rarely but swallowing problems such dysphagia, dental and oral pharyngeal problems are more common. Moving on certainly financial problems, and then the dementia related behaviors such as agitation or wandering can interfere with nutrition . Screening for hyperthyroidism and hyperparathyroidism will help us pick up some of the medical problems. Thinking about eating problems just not the oral pharyngeal. Then enteric problems must be considered , then the L’s stretches the mnemonic a little bit by thinking about Low salt diets and other things and then, of course, shopping and social isolation. On the next slides we’ll review each of these topics.
Adapted from Morley JE, Evans WJ et al. Anorexia in the Elderly: An Update.
Nutrition Literature Resource Compendium
Supplement to Annals of Long Term Care. 2001

14. Medications & Medical problems
General categories of ANORECTIC medications:
Antidepressants (SSRI’s)
Aceytlycholinesterase Inhib.
Cardiac glycosides
Anti-inflammatory
Diuretics
Antineoplastic
Oral hypoglycemics
Anticonvulsants
Psychotropic
Antacids
Phenothiazines
M edical problems
Cancer-most common of all medical problems for weight loss*
Infections -cause of malnutrition in 15-20%
COPD -  energy needs due to  work of breathing
CHF-associated with anorexia and protein losing enteropathy Macdonald N J Am Coll Surg July 2003;197: Gazzotti C, et. al.. Age and Aging 2003:32; High KP, Aging and infectious disease CID 2001:33 ecember
For medications it’s better perhaps to think of general categories than specific drugs. Here we’ve listed some of the common offenders. Heading the list are SSRI’s, acetylcholinesterase inhibitors through their cholinergic effect creating some nausea, cardiac glycosides (digoxin and digitoxin), which can have this effect even with normal dig levels. A good tip with dig is to always work to keep patients to the lowest effective dig level or even consider whether or not they need it at all. Mild effects from diuretics can occur, obviously antineoplastic drugs are famous for doing this. Occasionally an oral hypoglycemic can do this and suppressant effects from the anticonvulsants. Psychotropic medications can do this, however, more recently we have seen weight gain with some of the atypical antipsychotics. Finishing out the list are antacids and phenothiazines. One approach with your failing to thrive elder losing weight is to carefully prune the med list down to avoid these types of medications.
Delay the appearance of the R hand column until narrative of L column done
For medical problems cancer is probably the most common yet it’s still less than 20% of all causes of weight loss. For those in the community losing weight, less than 5% is due to cancer. Infections are a malnutrition contributors and account for up to 15-20% of unintentional weight loss. COPD, which I think we’re all very familiar with, through the increased work of breathing and energy needs. Up to 33% of severe COPD folks are malnourished. Lastly, congestive heart failure will produce an anorexia and may add a protein losing enteropathy. Here we find an increase in the cytokines causing increased resting energy expenditure, decreased albumin and decreased appetite.

15. “MEALS ON WHEELS” E motional problems (Depression)
---most common reversible cause of weight loss
Outpatients:--up to 30% [i]
NH pts % [ii]
Treatment of depression gives weight gain [iii],[iv]
[i] Kahn R. Weight loss and depression a community nursing home JAGS 1995;43:83
[ii] Rigler SK, Webb MJ, et al. Weight outcomes among antidepressants users in nursing facilities. JAGS 49;
[iii] IrvingGF, Olsson BA, Cederholm T, Gerontology 1999;45:
[iv] Fitten U, Morley JE, Gross PI, et al. Depression JAGS 1989;37:
Antidepressants with appetite stimulation
Mirtazapine (Remeron)
intial dose:7.5 mg q hs
Max. dose:30 mg q hs
Trazadone
intial dose: 25 mg q hs
Max. dose: 100 mg q hs
Delay the appearance of the R hand column until narrative of L column done
Emotional problems, which were somewhat addressed earlier, are actually the most common cause of reversible weight loss in the elderly. In nursing home patients up to 36%. In outpatients up to 30% of the population may have depression as their presenting feature. On the right hand side, which we’ve reviewed earlier, are some of the antidepressants that assist with appetite stimulation. Recall that trazadone is a weak antidepressant but a good sleep aid.

16. “MEALS ON WHEELS” A lcoholism / A buse / A cid (stomach)
A lcoholism: undiagnosed or under appreciated alcohol use will contribute or cause weight loss;
Screen with:
Quantity and frequency plus CAGE questions
Jones TV, Lindsey BA, Yount P et al. J Gen Intern Med ;8:
Bercsi SJ, Brickner, PW,Saha DC.. Drug Alcohol Depend 1993;33:
A buse
A cid (stomach)
PUD, gastritis etc may present as anorexia or nausea alone in the elderly.
A very common cause that often gets underneath our radar screen is alcoholism. Things that make us suspicious are single people, often male, living alone and losing weight are suspect. Screening with the CAGE questions has proved to be an effective way of picking up some elders.
Screen with:
CAGE plus questions of quantity and frequency 
CAGE:
C “have you felt you ought to CUT down on your drinking
A “Have people ANNOYED you by criticizing your drinking?”
G “Have you ever felt bad or GUILTY about your drinking?”
E “Have you ever had a drink first thing in the morning EYE opener
How good is the CAGE? Community Frail homebound
With score of > 1----sensitivity: 88%[i],[ii] 60%[iii]
Specificity % 100%
Delay the appearance of the R hand column until narrative of L column done
Abuse in this case usually refers to self neglect. In the Omaha area in 2000, up to 35% of abuse cases were actually self neglect. Here the individual either wittingly due to eccentricities or financial problems neglects their own nutrition, or unwittingly through dementia is not able to organize themselves to provide adequate nutrition. In a smaller percentage of cases, vulnerable adults, as we see below, are deprived to a degree of adequate nutrition. The definition for abuse is presented.
Abuse is to cause or permit a vulnerable adult to be placed in a situation that endangers the person’s life or physical health, to be cruelly punished, deprived of necessary food, clothing, shelter or care, sexually abused, financially exploited or unreasonably confined
PUD, gastritis etc may present as anorexia or nausea alone in the elderly.
Acid or stomach acid causing peptic ulcer disease, gastritis, GERD, etc., can present as anorexia alone in up to 30% of the cases of this GI disease. Keep a strong level of suspicion especially in patients with either a prior history of these types of GI diseases, any subtle symptoms of these GI diseases, or if they are in the right risk setting. In difficult cases I have at times even suggested a trial of a proton pump inhibitor while the workup is in progress.

17. S wallowing problems: L ate life paranoia RARE “MEALS ON WHEELS”
(Psychiatric problems )
Late life paranoia
Late life mania
Anorexia nervosa
RARE
Thomas DR, Morely JE. Anorexia and weight loss in
elderly outpatients. Part I. Supplement to Annals of Long
term Care 2001
S wallowing problems:
-etiologies: neuromuscular, neurologic, or anatomical
-evaluation is best performed by speech therapy
-evaluation and therapy by speech therapy often results in improved nutrition.
 COMMON
Thomas DR, Morely JE.. Part I. Supplement to Annals of Long term Care 2001
Late life paranoia revolves around psychiatric problems and perhaps can be extended into the paranoia related to dementia. It’s not a very common etiology, as a matter of fact it’s rare, however, this often quickly stands out to the health care provider as a problem but is difficult to intervene. Swallowing problems certainly are much more common. Here we see the combination of neuromuscular, neurologic or anatomic. A good start is to have an evaluation performed by a speech therapist. Data demonstrates that these evaluations and subsequent therapy has improved results in nutrition.

18. “MEALS ON WHEELS” O ral problems (taste, teeth, olfactory)
-80% of NH residents have some degree of tooth loss
-ill fitting dentures result in food avoidance
-periodontal disease causally related to wt loss in elderly
Mouth
33% of NH residents have mucosal lesions.
Ettinger RL Aust. Dent. J. 1973;18:12-19
Weyant RJ, Newman AB, et.al. JAGS 52; , 2004
Dental problems, especially in elderly nursing home or elders living alone, can become a significant problem due to either personal neglect or financial concerns over getting dental care and can lead to dental problems that impair chewing and swallowing. Up to 80% of nursing home residents will have some degree of tooth loss. Commonly we see patients with ill fitting dentures due to aging and weight loss. Obviously, for many elders dentures are expensive and they do not wish to endure the cost to replace them but consideration should be given to re-lining the dentures which will allow them to fit better. Periodontal disease is often related to weight loss in the elderly so we should encourage regular dental hygiene. For example, in nursing homes the minimum is twice a day brushing with soft bristle brush and toothpaste. Surprisingly, at least in nursing home residents, we see up to 33% with mucosal lesions. These include sores from dentures, Candida, and the occasional cancer and viral lesion.

19. W andering and other dementia-related behaviors
“MEALS ON WHEELS”
W andering and other dementia-related behaviors
Factors:
-Excessive wandering
-Psychotropic medications
-Paranoid ideations
-Associated depression
-Insufficient time spent by staff in feeding
-Swallowing apraxia (must be reminded to swallow each mouthful.)
 No evidence demented have increased metabolism Lauque S, JAGS 52; , 2004
N o money (poverty)
Urban hospital population:
12% not having enough food
13% not eating for entire day
14% hungry but not eating as they could not afford food.
Should “trigger” Social service consult
Nelson K, Brown ME, et al. JAMA 998;279:
“N” in the mnemonic stands for no money – poverty. The statistics here are true. At least in urban populations, somewhere in the 10-20% range do not have the money and food to sustain themselves. Trying to get social services can make an impact on this.
The “W” in the mnemonic stands for wandering and other dementia behaviors. Those of you who do nursing home care know that trying to get an agitated severely demented elder to eat can be quite formidable. Sometimes their paranoia does not allow them to do this. We must watch closely for things we can correct such as; treating the paranoia, but more importantly, treating of depression that is co-morbid with dementia, and encouraging staff to be able to spend more time in nursing home resident during feeding. Elders with dementia may have a swallowing apraxia and need staff to remind them to swallow each mouthful. What has not been demonstrated though is that dementia increases metabolism.

20. “MEALS ON WHEELS” H yperthyroidism & E ating problems
H yperparathyroidism
E ating problems
(tremor, stroke, etc.)
OT evaluations and therapy can assist many.
assisting older people to feed is labor intensive
institution = 18 minutes/meal home= 99 minutes/ meal)
Hu T. Huong L Cartwright WS. : A pilot study Gerontologist 1986:26:
The mnemonic now progresses on to the “H” and “E”. The “H” reminds us to check for hyperthyroidism or hyperparathyroidism. The old mnemonic “moans, bones and abdominal groans” was taught to us to remind us that hypercalcemia for hyperparathyroidism can produce those symptoms.
Eating problems revolve around getting the food to the mouth and can include a whole host of thoughts: tremor, stroke, etc. Occupational therapists in either nursing home inpatient or outpatient can assist. Actual feeding of elders in institutions is very labor intensive. Currently, most states are mandated that feeders must be certified, therefore volunteers cannot do this. And here’s why it’s a problem. The average institutionalized person gets about 18 minutes to eat their meal, whereas, if that person was at home feeding with their caregiver it would take up to 99 minutes.

21. “MEALS ON WHEELS” L ow salt diet, E nteric problems
THERAPEUTIC DIETS can cause malnutrition in the elderly
WHY ?
fat diets – minimally effective on cholesterol
dietary fat produces most food flavor
regular diet no effect on NH residents with DM
minority of elderly hypertensives are salt sensitive Tariq S,. J Am Diet Assoc 2001;101(12):
E nteric problems
Constipation
(most common)
Malabsorption
L ow salt diet other therapeutic unpalatable diets
food preferences, consistency & temperature improve food intake Hotaling DL, Dysphagia 1992;7: Johnson RM, J Am Geratr Soc 1995;43:
Enteric problems is the lead GI cause of constipation. If they can’t have a bowel movement they won’t want to eat. Some other problems that will be fairly obvious to pick up are malabsorption. The leading symptom here is abdominal pain or, more likely, loose stools to diarrhea. Here some things to think about are celiac disease, short bowel syndromes, etc.
The “L” in the mnemonic reminds us to think about low salt diet and other therapeutically unpalatable diets. Patients in significant nutritional jeopardy, as defined in the beginning, need to have immediate consideration for discontinuance of any therapeutic diet as the nutritional element will more quickly cause their death than prevention of their other diseases. We know that in nursing home populations lifelong dietary habits are ignored and satisfaction of eating is reduced. Food temperature tightly regulated by federal laws both for safety and transit of food to the patient can sometimes be lower than what patients would prefer. We know that therapeutic diets can cause malnutrition in elders. Example; Low fat diets have a minimal effect on cholesterol but may really reduce the taste and consistency of many foods. Elders already have a decreased taste and smell and then fat which produces a great deal of flavor, when absent relegates this food to being “tasteless.” Salt, which may minimally affect elderly hypertensives when controlled, can have a significant effect on flavor. Lastly, some excellent studies actually demonstrated that diet control in frail nursing home residents had no effect on control of their diabetes. Hence, eating a regular nursing home diet that usually consists of calories, 3-4 gm fat, 30% fiber or more and 1 gm per kg per day of protein or more is just ideal for an elder and specialized “diabetic” diets are unnecessary.

22. “MEALS ON WHEELS” S hopping problems S ocial isolation
-(see above in “N o money (poverty)
-Should “trigger” Social service consult to explore ways to finance and assist with shopping .
S ocial isolation
-Woman eat 13% more when men are present
-Both genders eat more:
( 23%) with family present
(44%)  in groups
-Environment: pleasant, well-lighted unhurried mealtimes in social environment increases intake De Castro JM. Neurosci Biobehav Rev 1996;20: Morley JE, Nutrition 2001;17: Kayser-Jones J J Geron Nurs 1996;22:26-31
S, the last letter in the mnemonic stands for shopping problems and social isolation. We saw this before in the financially impaired elders, but this also can be a problem for the elders who are afraid or unable to get out to shop and have no one else to bring them food. Again, social services can assist them with this to find transportation or grocery stores that deliver. Social isolation is quite an important issue. Some interesting statistics are that women will eat 13% more when men are present. I supposed it’s because they fear the men are going to eat their food. Both genders will eat more if family is present or in groups so encouraging your elders to live in settings where they would have group meals and family members to attend is quite important. Environment seems to be important also. Many independent living centers realize this today, and they provide a hotel like dining experience that is pleasant, well lighted, unhurried, and that allows social interaction.

23. THANK YOU for your Kind Attention
This completes our second module on The Evaluation of 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 3 where we will complete the Evaluation of UNINTENTIONAL WEIGHT LOSS . Question 224

24. Question
A patient returns to the nursing home following hospitalization for pneumonia and superimposed delirium. A stage III sacral pressure ulcer developed during hospitalization because he was restrained to prevent him from removing an intravenous catheter. Weight in the hospital was 70 kg (154 lb), for a body mass index of 22.8; this is his “usual weight,” but it is only 90% of ideal. Cognitive level is near baseline; Mini–Mental State Examination score is 16/30. He is able to follow a two-step command and to sit independently but requires assistance with transferring, dressing, grooming, and toileting. Muscular weakness is apparent in the deltoids, with some squaring of the shoulders. The quadriceps also are weak and wasted. The patient has no difficulty swallowing liquids or solids. The nursing-home dietitian recommends that the patient resume his previous diet, which provided 2100 kcal daily, with 70 g of protein.
This completes our second module on The Evaluation of 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 3 where we will complete the Evaluation of UNINTENTIONAL WEIGHT LOSS . Question 224

25. Which of the following should you advise?
A. Institute oral liquid supplements with meals.
B. Resume the previous diet.
C. Increase protein intake to at least 105 g daily.
D. Increase caloric intake to at least 2400 kcal daily.