1. By: Nicole Greene NUTRITION INTERVENTIONS IN THE ANOREXIC GERIATRIC PATIENT

2. AGENDA Defining Geriatrics Physiologic Changes of Aging Psychological Changes with Aging Medical Nutrition Therapy of the Malnourished Geriatric Patient Presentation of M.C. Critical Comments Summary Questions References

3. INTRODUCTION Aging can’t be prevented Malnutrition In the elderly often overlooked How does physiologic, mental, and psychological changes affect nutrition in the elderly population? How can an early nutrition intervention improve quality of life?

4. DEFINING GERIATRICS Greek origin Geron– elder Iatros- healer Sub-specialty of internal and family medicine focused on prevention and treatment of diseases and disabilities in the elderly Many countries have accepted the age of 65 as the definition of “elderly”

5. GERIATRIC POPULATION

6. PHYSIOLOGIC CHANGES ASSOCIATED WITH AGING Different than treating a mid aged adult Problems arise from choices made in their history Changes can be summarized into several categories relating to the organ systems they compromise Every patient unique and may be experiencing different problems

7. BONE, MUSCLE, AND JOINT ISSUES IN THE ELDERLY Decreased Movement for day-to- day activities Decreased Bone Density Stiff Joints/Arthritis Muscle Mass Diminishes

8. CARDIOVASCULAR CONDITIONS IN GERIATRIC PATIENTS Atrial Fibrillation Hypertension Coronary Artery Disease Myocardial Infarction Congestive Heart Failure Valvular Disease

9. RESPIRATORY CONDITIONS IN THE ELDERLY Decreased elastin Decreased vital capacity Decrease # of alveoli Decrease # of celia

10. GI SYMPTOMS IN THE ELDERLY Decrease in saliva production Esophageal dysfunction Atrophic gastritis Achlorhydria Decreased liver metabolism Decreased absorption-lactose, calcium, iron

11. CHANGES IN THE ELDERLY’S URINARY SYSTEM Vascular blood flow to the kidneys decreases Nephrons decrease Decreased tissue mass Bladder wall become less elastic

12. CHANGES IN THE ELDERLY’S NERVOUS SYSTEM Central processing of eye is decreased Hearing losses Slowing down of thought and memory DEMENTIA IS NOT A NORMAL PROCESS OF AGING

13. CHANGES IN THE ELDERLY’S IMMUNE SYSTEM Increased Illness and Infection Shrinking of Thymus Gland Decline in number of antibodies

14. PSYCHOLOGICAL ASPECTS OF AGING Psychological, biological, environmental, and genetic factors all contribute to depression Depression last longer in the elderly and increases the risk of death from illness

15. MALNUTRITION Malnutrition  Increased morbidity and mortality in elderly Lack of protein, energy, and other nutrients causes adverse effects on tissue form, composition, function, or clinical outcome The ADA/A.S.P.E.N. has developed criteria to diagnose malnutrition in adults Serum proteins such as albumin and prealbumin are not included as defining characteristics of malnutrition

16. DIAGNOSTIC TOOL TO IDENTIFY MALNUTRITION Moderate Malnutrition Severe Malnutrition Moderate Malnutrition Severe Malnutrition Moderate Malnutrition Severe Malnutrition Food and Nutrient Intake 7 d ays ≤ 50% of est. energy requirement for ≥ 5 days < 75% of est. energy requirement for ≥ 1 m ≤ 75% of est. energy requirement for ≥ 1 m < 75% of est. energy requirement for ≥ 3 m ≤ 50% of est. energy requirement for 1 ≥ m Interpretatio n of Weight Loss 1-2%: 1 wk 5%: 1 m 7.5%: 3 m >2%: 1 wk >5%: 1 m >7.5%: 3 m 5%: 1 m 7.5%: 3 m 10%: 6 m 20%: 1 yr >5%: 1 m >7.5%: 3 m >10%: 6 m >20%: 1 yr >5%: 1 m >7.5%: 3 m >10%: 6 m >20%: 1 yr >5%: 1 m >7.5%: 3 m >10%: 6 m >20%: 1 yr Clinical Charachteri stic Malnutrition in the context to acute illness or injury Malnutrition in the context of chronic illness Malnutrition in the context of social or environmental circumstances

17. CAUSES OF MALNUTRITION IN THE GERIATRIC POPULATION Poor appetite Chronic illness Multiple medications Cognitive decline Physiologic weakness Oral health Dysphagia Diarrhea or constipation Economic hardship

18. CONSEQUENCES OF MALNUTRITION Morbidity and mortality Greater risk for infections Cachexia Failure to thrive Delayed wound healing Impaired respiratory function Muscle weakness Depression

19. ASSESSING THE MALNOURISHED GERIATRIC PATIENT Physical signs Muscle wasting Temporal wasting Poor skin integrity Delayed healing Subcutaneous fat loss Hair loss

20. ASSESSING THE MALNOURISHED GERIATRIC PATIENT Body Mass Index BMIInterpretation <15Severely Underweight <18.4Underweight 18.5-24.9Normal 25-29.9Overweight 30-34.9Obesity Grade I 35-39.9Obesity Grade II >40Obesity Grade III 23-27Normal for Elderly (65 and older)

21. ASSESSING THE MALNOURISHED GERIATRIC PATIENT Interpretation of % Weight Change Time(%) Significant wt loss (%) Severe wt loss 1 week1-2>2 1 month5>5 3 months7.5>7.5 6 months10>10 Unlimited time10-20>20

22. ASSESSING THE MALNOURISHED GERIATRIC PATIENT FAILURE TO THRIVE Syndrome manifested by weight loss greater than 5 percent of baseline, decreased appetite, poor nutrition, and inactivity Four syndromes are prevalent and predictive of adverse outcomes in patients with FTT: Impaired physical function Malnutrition Depression Cognitive impairment

23. CLINICAL MANIFESTATIONS OF REFEEDING SYNDROME HypophosphatemiaHypokalemiaHypomagnesemiaVitamin/Thiamine Deficiency Sodium Retention hypoxiaNausea/VomitingWeaknessEncephalopathyFluid overload Impaired cardiac function ParalysisMuscle TwitchingLactic AcidosisPulmonary Edema Respiratory failureMuscle NecrosisAnorexiaDeath WeaknessAlterations in myocardial contraction Nausea Vomiting Diarrhea Cardiac Decompensation ConfusionElectrocardiograph changes RestlessnessCardiac Arrhythmias SeizuresSudden DeathSeizures ComaweaknessComa DeathRespiratory compromise Death

24. ESTIMATING NUTRITIONAL NEEDS IN THE MALNOURISHED GERIATRIC PATIENT Caloric Needs Weight based calculations  use actual weight for normal and underweight individuals BMIInterpretationKcal/KG <15Severely Underweight 35-40 <18.4Underweight 30-35 18.5-24.9Normal 25-30 25-29.9Overweight 20-25 >30Obesity 15-20 23-27Normal for Elderly 22-28

25. ESTIMATING NUTRITIONAL NEEDS IN THE MALNOURISHED GERIATRIC PATIENT Caloric Needs The Academy suggests a dietary prescription of 130% of the REE, but should be avoided when the patient is at risk for refeeding syndrome Penn State equation or Ireton Jones for critically ill

26. ESTIMATING NUTRITIONAL NEEDS IN THE MALNOURISHED GERIATRIC PATIENT Protein Needs: Nourished0.8-1.0 g/kg Malnourished1.2-2.0 g/kg *Wounds and different disease states also may increase or decrease protein needs

27. ESTIMATING NUTRITIONAL NEEDS FOR REFEEDING SYNDROME Start low and go slow Protein should not exceed 1-1.5 gm/kg of normal weight in the early stages of refeeding Calories: 20-25 kcal/kg actual body weight If feeding Parenterally: CHO load start with 2 mg/kg/minute- prevents gluconeogenesis and minimizes insulin secretion Restrict fluids to avoid edema MONITOR LABS: ESPECIALLY PHOSPHORUS, POTASSIUM, AND MAGNESIUM

28. METHODS OF FEEDING THE MALNOURISHED GERIATRIC PATIENT Oral Feeding Liberalizing the diet Add High Calorie/High protein supplements Enteral Nutrition Can’t be fed orally or can’t meet needs orally Parenteral Nutrition Should only be initiated when medically necessary

29. OTHER INTERVENTIONS Possible medication changes Remeron Appetite stimulants

30. EVALUATING FEEDING SUCCESS IN THE MALNOURISHED GERIATRIC PATIENT Weight gain (not in fluid) Healing wounds Nitrogen balance A positive nitrogen balance suggest that nutrition intake is adequate to promote anabolism and preserve lean muscle mass Negative nitrogen balance is when nitrogen excretion exceeds intake, reflecting muscle deterioration

31. PRESENTATION OF PATIENT: MC 68-year-old widowed Caucasian female Transferred from Lions Gate Nursing Home for SOB and tachycardia The patient apparently was not eating at all and is eating less than 5% of her diet report from Lions Gate Nursing Home Weight is only 55 pounds The patient was admitted here for psych evaluation for commitment and inpatient treatment

32. INITIAL NUTRITION ASSESSMENT (4/18/12) Physician and RN consult, Calorie Count Consult Diagnosis: COPD Anorexia Tachycardia Hx: COPD FTT Cachexia Kyphoscoliosis Osteoporosis Hypokalemia Depression Gait Instability

33. FOOD/NUTRITION HISTORY Transferred from Lyons Gate Nursing home AAOx3 PO ~5% per nursing records Per H&P: Pt. refuses to eat, hides food, and throws up after meals Calorie count initiated today Pt. likes ensure and needs soft food Noted poor intake x 7 years since husbands death (weight was 126#) Per noted record: weight stable at 75# in July 2011 ? At risk for refeeding Current Diet Order: General Diet +Ensure TID+ Ensure pudding BID, RN to watch pt. eat meals Does not meet needs: pt. needs soft

34. LABS: Lab ValueNormal RangeCurrent ValueNutritional Significance Hemoglobin12.0-16.0 g/dL12.3- Hematocrit34.9-44.9%36.2- Sodium133-145 mmol/L139- Potassium3.3-5.1 mmol/L3.4- BUN6-20 mg/dL6- Creatinine0.40-1.10 mg/dL <0.30 L Muscle injury/ decreased muscle mass, low protein diet Glucose80-115 mg/dL 67 L Missed meals Calcium8.8-10.0 mg/dL 8.2 L Hypoalbuminemia, deficiency, low Vit. D, malnutrition, osteoporosis Phosphorus2.7-4.5 ml/dL 2.3 L malnutrition Magnesium1.6-2.6 ml/dL1.6- Albumin3.5-5.3 g/dL 3.1 L Inflammation, malnutrition Prealbumin17-35 mg/dL 10.7 L Malnutrition, infections Protein5.9-8.3 g/dL 5.2 L Malnutrition, malabsorption

35. MEDICATIONS MedicationUse ProtonixGERD PrednisoneInflammation HeparinPrevent blood clots RemeronDepression/Appetite Stimulant Oscal/Vit D 500-200Osteoporosis K-DurPrevent Hypokalemia MarinolAppetite Stimulant VentolinCOPD

36. ANTHROPOMETRICS: Height5’0 Weight55 lb or 25 kg UBW75 lb or 34 kg (July 2011 or 8 months ago) % Weight Change27% in 8 months IBW96-125 lb or 44-57 kg % IBW57 % BMI10.7 PHYSICAL EXAM FINDINGS: -Multiple Stage I and II Pressure Ulcers- Wound care pending -Temporal Wasting -Poor Dentition -Hair Loss

37. NUTRITIONAL NEEDS Calories 625 kcal  will increase needs once clear from refeeding Based on 25 kg weight 25 kcal/kg Protein 34-51 g Based on 34 kg (UBW) 1-1.5 g/kg Fluid ~1290 ml Based on 43 kg (IBW) 30ml/kg

38. NUTRITIONAL DIAGNOSIS Suboptimal oral food beverage intake related to disordered eating as evidenced by weight loss of 26% over 8 months (severe), anorexia secondary to depression, BMI: 10.7, 57% of IBW Goal: PO intake >50% of each meal/supplements within 3 days (calorie count)

39. MONITORING AND EVALUATION: High acuity Weight PO intake/ kcal count Electrolytes (Na, K, Mg, PO4) Skin/Wound Care-pending Psych Consult- pending Increased needs

40. NUTRITION INTERVENTIONS Nutrition Education: Verbal needs for tolerating PO/Increased needs Coordination of Other Care During Nutrition Care: RN, Physician, and Calorie Count at Bedside Recommend: Check CRP, Folate, B12, Vit. D Start MVI daily Change diet to mechanical soft with ground meats Pt. would benefit from PEG tube/encourage feeding tube and consider GI consult for placement Monitor Electrolytes- may be at risk for refeeding Consider 1:1 for questionable purging

41. CALORIE COUNT NOTE (4/19/12) PO intake poor secondary to eating disorder Pt. PO 250 kcal, 7 gm protein Minimal PO at breakfast and no PO at dinner Pt. reports no appetite, but may be agreeable to PEG Pt. complains of early satiety Recommendations: As able, GI to F/U with pt. referring increased anxiety with PEG procedure

42. UPDATE! (4/19/12) Spoke with patient  now agreeable for PEG Consulted GI Will await pulmonary clearance Recommend: Once PEG placed, initiate Jevity 1.2 @ 20 ml/hr and increase by 10 ml q 4 hr until at goal rate of 40 ml/hr x 12 hr 480 ml total volume 576 kcal 27 g Pro 687 ml total H20

43. NUTRITION FOLLOW UP (4/21/12) A Pt. ordered clear liquid diet Calorie count range: 200-500 kcal/day POD #1 S/P PEG placed Jevity 1.2 @ 10ml @present (goal is 40 ml x 12hr/day with AF) Pt. AAOx3 in good spirits POC: rehab@ D/C Once PEG feeds tolerated at goal 40mlx12 hr (576 kcal, 27 gm pro, 687 ml H2O), will progress or change feeds to bolus. No new lab data

44. NUTRITION FOLLOW UP CONTINUED (4/21/12) D Suboptimal EN related to goal not yet reached as evidenced by EN @ 10 ml/hr (goal is 40 ml/hr x 12 hr) Goal: EN to meet estimated needs within 48 hours/ PO feeds for supplemental I Closely monitor electrolytes Progress PO diet to mechanical soft with ensure BID Oral care/ HOB Jevity 1.2 @ goal 40 ml/hr x 12 hr/day with AF

45. NUTRITION FOLLOW UP CONTINUED (4/21/12) M/E: High Acuity PO intake Electrolytes EN tolerance S/S of aspiration Wound Healing

46. NUTRITION FOLLOW UP (4/24/12) A: Diet: mechanical soft general diet+ ensure TID+ ensure pudding BID Jevity 1.2 @ goal rate of 40 ml/hr x12 hr via PEG Oral PO 0% per RN flow and pt. report EN feeds well tolerated Would benefit from increased needs with stable electrolytes

47. NUTRITION FOLLOW UP CONTINUED (4/24/12) Estimated needs: 875-1000 kcal 35-40 kcal/kg Based on 25 kg weight 66-88 g pro 1.5-2.0 g pro Based on IBW 1275 ml H2O Based on IBW ~30 ml/kg

48. NUTRITION FOLLOW UP CONTINUED (4/24/12) Additional Medications Milk of Magnesia Senokot Zofran Labs 67 L 132 L 3.5 93 L 33 H 12 <0.30 L

49. NUTRITION FOLLOW UP CONTINUED (4/24/12) D: Increased nutrient needs related to protein/energy malnutrition as evidenced by muscle wasting and temporal wasting Goal: pt. will meet estimated needs within 24 hours I: Jevity 1.2 @ 60 ml/hr x 12 hr (7pm-7am) + 2 oz liquid protein via PEG Provides: 720 ml total volume 864 kcal + 120 (liquid pro) = 984 kcal 40 gm pro + 30 gm (liquid pro) = 70 gm pro Free H2O with AF: 806 ml

50. NUTRITION FOLLOW UP CONTINUED (4/24/12) M/E: Weight Electrolytes, prealbumin EN tolerance Skin/Wound Healing Increased needs with weight gain

51. CRITICAL COMMENTS: Improvements Diet would have overfed patient Should have used actual body weight for protein/fluid Nurse couldn’t watch patient eat tray Mg and PO4 labs weren’t ordered Positives Communication between multidisciplinary team Gaining patient’s trust

52. SUMMARY: Geriatric population rapidly growing Physical and mental changes occur with aging which may lead to decreased intake Multidisciplinary team must be proactive in identifying warning signs, preventing, and treating malnutrition MC example of malnourished geriatric patient 3 weeks later, I went to visit MC and she had gained 8.8 pounds. MC was working with PT to walk with a walker, but oral intake was still minimal

53. QUESTIONS??

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