Considerations in Nutrition Support for Older Adults

Question 1

Pharmacologic agents such as histamine2-receptor antagonists (H2 blockers) and proton-pump inhibitors (PPIs) are commonly prescribed for a variety of upper GI disorders for the prevention of gastric ulceration. Prolonged use of these medications may contribute to deficiency of this of the following micronutrients?

1: Iron
2: Potassium
3: Vitamin B6
4: Vitamin B12

Answer 1

Vitamin B12

Risk of developing vitamin B12 deficiency increases with age as gastric acid production declines with age, and also with use of acid lowering medications (H2 blockers and PPIs). Vitamin B12 bound to food must be released from the protein, a process that requires the presence of gastric acid and gastric peptic activity. After being released from the protein, the B12 molecule binds with intrinsic factor and is absorbed in the small intestine. Vitamin B12 deficiency has been associated with use of both H2 blockers and PPIs among older adults, particularly those receiving PPIs over the course of several years, even when being supplemented with oral B12-containing vitamins. Although the literature is mixed in whether H2 and PPI use can lead to B12 deficiency, this is likely due to differing definitions of what constitutes vitamin B12 deficiency. Clinicians should be contentious of vitamin B12 status in older adults receiving acid lowering medications.

Question 2

An 85 year old nursing home resident was transferred to the hospital with anorexia, malnutrition, and probable aspiration pneumonia. Which of the following nutrition intervention would be most appropriate for this patient?

1: Regular diet with supplements
2: Establish central access and initiate parenteral nutrition
3: Obtain peripheralaccess and initiate peripheralparenteral nutrition
4: Initiate enteral nutrition and consult for swallowing evaluation

Answer 2

Initiate enteral nutrition and consult for swallowing evaluation

The most appropriate intervention is to provide enteral feedings. Since there is no evidence of compromised gastrointestinal function, parenteral nutrition is not indicated. Transitioning to an oral diet with supplements may be appropriate once safety of oral intake is established following a swallow evaluation.

Question 3

Which of the following medications is most likely to cause constipation in a patient receiving enteral nutrition (EN)?

Answer 3

Codeine

Medications are a common cause of diarrhea in patients receiving enteral nutrition. Some medications induce a hyperosmolar environment within the gastrointestinal (GI) tract, pulling fluid into the GI tract and causing a laxative effect, such as those that contain magnesium or sorbitol, and kayexalate. Antibiotics commonly cause loose stool by decreasing beneficial microbiota within the GI tract, and some may increase the risk of C. difficile overgrowth. Codeine may actually decrease GI motility and contribute to constipation; long term use of opioids may contribute to overflow diarrhea where liquid stool flows around stool blockage.

Question 4

Which of the following is NOT appropriate to tell a family regarding nutrition at the end of life?

1: Dying patients rarely feel hungry or thirsty
2: Fewer calories are needed at the end of life
3: The experience of eating remains unchanged at the end of life
4: Patients should not be made to feel guilty if they do not wish to eat

Answer 4

The experience of eating remains unchanged at the end of life

It is important for family members to be educated regarding the process of decreased food/fluid intake during the dying process. As illness advances, nutritional needs change and fewer calories are needed. The experience of eating can change from a pleasant one to a distressing one for a patient as the disease process alters the patient’s desire to eat. Dying patients rarely feel hungry or thirsty because the natural process of dying shuts down normal functions. Patients should not be made to feel guilty if they do not try to eat. Diminished food and fluid intake are natural parts of the dying process

Question 5

A patient in a persistent vegetative state has made their wishes known regarding artificial nutrition and hydration whose wishes have been made known through an advance directive. The decision to terminate enteral feeding for this patient is based on the ethical principle of

1: justice.
2: autonomy.
3: beneficence.
4: nonmalfeasance.

Answer 5

Autonomy

If an incompetent individual has an advance directive regarding artificial nutrition and hydration, the principle of autonomy should guide the health care team in making a decision regarding artificial nutrition and hydration. If an advance directive is not available, the principles of beneficence and nonmalfeasance are more central. Autonomy, beneficence, nonmalfeasance, and justice are the four ethical principles. Autonomy is an ethical principle based on respecting and upholding the patient’s right to self-determination. Beneficence is definedan ethical principle in whichas when health care providers actively seek the good of the patient above all other priorities. Nonmalfeasance, “to do no harm” relates to health care providers actively seeking to prevent, minimize and relive needless suffering and pain avoid harming the patient. Justice is related to the fair distribution of resources.

Question 6

Which of the following best reflects the use of artificial nutrition and hydration (ANH) in patients with a Do Not Resuscitate (DNR) status?

1: The DNR status is a contraindication to the provision of ANH
2: The DNR status should not preclude the initiation of ANH if the indications exist
3: The provision of AND to a patient with a DNR status is based on individual state laws
4: ANH cannot be withheld or withdrawn in a patient with a DNR order, even if all agree that SNS is no longer meeting the desired goal

Answer 6

2: The DNR status should not preclude the initiation of ANH if the indications exist

A Do Not Resuscitate (DNR) or Do Not Attempt Resuscitation (DNAR) order is not a contraindication to the provision of ANH in any state. If the indications for ANH exist, then ANH should be implemented, even as a time-limited trial. ANH can be withheld or withdrawn in patients with a DNR or DNAR if all concerned agree ANH is not meeting the agreed-upon goal.

Question 7

Which of the following best describes the use of artificial nutrition and hydration (ANH) in terminally ill patients?

1: Those who receive ANH have a more comfortable death
2: Those who have dysphagia survive longer with ANH
3: Those who receive ANH have a decrease in abnormal electrolytes
4: Those who receive no ANH do not experience more negative side effects than those who do

Answer 7

4: Those who receive no ANH do not experience more negative side effects than those who do

A common fallacy in terminally ill patients is that dehydration is thought to be an uncomfortable state. At the end of life, patients rarely complain of thirst, and aggressive artificial nutrition and hydration (ANH) can be more harmful and can produce life-threatening symptoms. Decreased nutritional intake stimulates increased production of endorphins and dehydration leads to increased dynorphin levels. Both endorphins and dynorphins are natural analgesics and may increase comfort levels. Numerous studies report that patients who are dying predominately have electrolyte values that run in the normal range.

Question 8

A patient has an advanced directive stating a desire to forego medical technology, including nutrition and hydration, in order to prolong life. The patient is now in an irreversible vegetative state. In deciding whether to continue nutrition and hydration by medical means, the patient’s surrogate decision-maker must:

1: consult with a lawyer.
2: have a psychiatric evaluation to be declared competent to make any decisions in the patient’s care.
3: honor the patient’s expressed wish to withdraw nutrition and hydration by medical means.
4: decide, based upon own values, to make a decision to withdraw the patient’s nutrition and hydration by medical means.

Answer 8

3: honor the patient’s expressed wish to withdraw nutrition and hydration by medical means.

In the Cruzan case, the US Supreme Court assumed that a competent individual has the same right to refuse life-sustaining treatment (including nutrition and hydration by medical means) as to refuse any other kind of medical intervention. Where evidence of an incompetent person’s previously expressed wish not to be kept alive by medical technologies meets state evidentiary standards, the exercise of that choice by a surrogate decision-maker must also be honored.

Question 9

In an older adult who requires long term EN, which of the following complications is most often overlooked?

1: Tube leaking
2: Constipation
3: Decreased urine output
4: Skin problems at tube site

Answer 9

Decreased urine output

Although decreased urination, tube clogging, tube leaking and skin problems at tube site are all commonly reported patient complications of home EN, decreased urination has been found to be the most common complication in a group of elderly patients receiving home enteral nutrition. Decreased urination likely indicates inadequate fluid intake while on enteral feeding and the potential for dehydration and risk for acute kidney injury

Question 10

Vitamin D (25, hydroxyvitamin D) deficiency is defined as a serum level of less than

1: 100 ng/mL.
2: 20 ng/mL.
3: 50 ng/mL.
4: 120 ng/mL

Answer 10

2: 20 ng/mL.

Measuring serum 25, hydroxyvitamin D [25(OH)D] can determine vitamin D adequacy. A 25(OH)D value between 21-29 ng/ml signifies vitamin D insufficiency. A 25(OH)D value < 20 ng/ml is indicative of vitamin D deficiency. A 25(OH)D level ≥30 ng/ml is representative of adequate vitamin D stores.

Question 11

Vitamin D (25, hydroxyvitamin D) deficiency can manifest as

1: muscle weakness.
2: decreased production and excretion of parathyroid hormone (PTH) levels.
3: hypotension.
4: less than normal serum lipid levels.

Answer 11

1: muscle weakness.

Older adults are more at risk for vitamin D deficiency since they are more likely to stay indoors, have reduced ability to synthesize vitamin D in the skin when exposed to sunlight, use sunscreens and have inadequate vitamin D intake. There are vitamin D receptors (VDRs) throughout the body including the parathyroid glands, muscle tissue, cardiovascular system and kidneys. Without vitamin D binding to VDRs, parathyroid hormone excretion is reduced resulting in increased production of PTH; stimulation of muscle fibers is decreased causing muscle weakness; renin activity is increased resulting in hypertension; and there is a potential for hyperlipidemia given the need for vitamin D in lipid cell membranes formation.

Question 12

Which of the following is the hallmark of frailty seen with older adults?

1: Sarcopenia
2: Chronic inflammation
3: Dementia
4: Chronic disease

Answer 12

1: Sarcopenia

While chronic inflammation, dementia, and chronic disease may be noted, sarcopenia (loss of muscle mass and strength) is a hallmark of frailty along with unintentional weight loss (10 pounds in past 1 year), self-reported exhaustion, weakness, slow walking speed, and low physical activity. Inflammation, chronic disease, inadequate nutrition, and oxidative stress also play a role in frailty. Nutrition interventions have not improved outcomes associated with frailty.

Question 13

Which of the following complications of enteral nutrition (EN) is the most potentially dangerous in the older adult?

1: Diarrhea
2: Abdominal distension
3: Leaking around the enterostomy tube insertion site
4: Aspiration

Answer 13

Aspiration

Gastroesophageal reflux can occur as a result of diminished gastric emptying. Pulmonary aspiration may result from reflux and is one of the most serious complications of EN. It can lead to pneumonia or death. While diarrhea, abdominal distension, and leaking are undesirable, their overall impact on morbidity and mortality are not as great as that of aspiration.

Question 14

A 75 year old male with history of aspiration pneumonia who was previously deemed unsafe for an oral diet is now experiencing aspiration while receiving continuous enteral nutrition via his percutaneous endoscopic gastrostomy (PEG) tube. Which of the following long-term feeding options would be the most appropriate?

1: Peipheral parenteral nutrition (PN)
2: Central parenteral nutrition (PN)
3: Nasojejunostomy tube placement
4: Percutaneous endoscopic jejunostomy (PEJ) feeding

Answer 14

Percutaneous endoscopic jejunostomy PEJ feeding

Small bowel feedings are the preferred choice in patients at increased risk for aspiration. PEJ tube placement would allow delivery of nutrients into the jejunum, which may minimize the potential for reflux and aspiration. PEG feedings are an option, though since this patient has already demonstrated aspiration with continuous PEG feeds and unable to consume nutrition orally, long-term small bowel access would be the best plan to prevent aspiration in the long term. Parenteral nutrition is not indicated for this patient.

Question 15

An older adult patient without IV access requires strict bowel rest and PN for 6 weeks. Which of the following vascular access devices should be employed?

1: A port
2: Peripherally inserted central catheter (PICC)
3: Small bore antecubital peripheral access
4: Intra-jugular (IJ) central venous catheter

Answer 15

2: Peripherally inserted central catheter (PICC)

PN through a PICC line is appropriate for a 6 week course of therapy. Peripheral PN is discouraged for use longer than 2 weeks due to the difficulty in providing adequate protein and calories and because of the difficulty in maintaining peripheral access. A short term central venous catheter should not be maintained for 6 weeks and would require replacement. A port would require surgical implantation and is generally indicated for long-term use (greater than 6 weeks).

Question 16

According to the 2012 National Inpatient Sample (NIS) of hospital discharges, what percentage of older adults greater than 65 years old, were diagnosed with malnutrition?

1: 10-20%
2: 30-40%
3: 50-60%
4: 70-80%

Answer 16

2: 30-40%

According to the 2012 NIS, 34.8% of hospitalized patients greater than 65 years old were discharged with malnutrition coded as a diagnosis. This discharge data was based on 35,484,846 hospital discharges in the U.S. with an average length of stay of 4.5 days. This data included 12,704,704 hospital discharges for those patients greater than 65 years old.

Question 17

Which of the following represents the core set of clinical and functional status elements which form the foundation of the comprehensive assessment for all residents of long-term care facilities certified to participate in Medicare or Medicaid?

1: Minimum Data Set (MDS)
2: Resident Assessment Protocols (RAP)
3: UtilizationGuidelines
4: Trigger Legend

Answer 17

1: Minimum Data Set (MDS)

The Omnibus Budget Reconciliation Act (OBRA) of 1987 provides the total assessment and process for facilities certified to participate in Medicare or Medicaid programs. The MDS is a core set of clinical and functional status elements, and it forms the foundation of the comprehensive assessment for all residents of long-term care facilities certified to participate in Medicare and Medicaid. The MDS is a part of the Resident Assessment Instrument (RAI), a problem identification model. In addition to the MDS, other components of the RAI include resident assessment protocols (RAPs) and utilization guidelines. RAPs are composed of triggers, trigger legends, RAPs analysis, and RAPs summary sheet.

Question 18

Which one of the following vitamin deficiencies is most likely to occur in an older adult who consumes alcohol on a regular basis?

1: Vitamin K
2: Vitamin B9
3: Vitamin D
4: Vitamin B1

Answer 18

4: Vitamin B1

Older adults have a lower tolerance for alcohol due to the effects of aging. Long-term alcohol abuse may lead to Wernicke-Korsakoff syndrome, which is associated with thiamin deficiency. Regular alcohol intake can affect absorption and utilization of vitamins B6, B12 ,C and fat soluble vitamins as alcohol inhibits fat absorption and thereby impairs absorption of the vitamins A, E, and D that are normally absorbed along with dietary fats. Additionally, altered iron and zinc absorption may occur.

Question 19

Which of the following medications is most likely to contribute to hyponatremia in an older adult?

1: Hydrochlorothiazide
2: Amlodipine
3: Warfarin
4: Simvastatin

Answer 19

Hydrochlorothiazide

Thiazide or thiazide-like diuretics are the most common causative agent associated with diuretic-induced hyponatremia. Thiazide diuretics act solely in the distal tubules, and do not interfere with urinary concentration and the ability of antidiuretic hormone to promote water retention. This is from the thiazide induced Na+ and K+ loss with ADH induced water retention. In comparison, loop diuretics (furosemide) can actually diminish ADH induced free water free water absorption and treat hyponatremia in SIADH.The other agents listed are not commonly considered agents which lower serum sodium.

Question 20

An older adult nursing home resident with a history of constipation has a newly placed percutaneous endoscopic gastrostomy (PEG) tube. Which of the following fiber formulas would most likely be the best choice?

1: Concentrated 2 kcal/mL formula
2: Standard 1 kcal/mL formula
3: High protein 1 kcal/mLformula
4: Elemental 1.5 kcal/mL formula

Answer 20

2: Standard 1 kcal/mL formula

Constipation is common in the elderly. In addition to providing adequate fluid, a fiber-containing formula may help minimize constipation. Fiber helps propel waste through the colon. If fiber is added to the enteral regimen, patients should receive a minimum of 1 mL of fluid per kcal to prevent solidification of waste in the colon and constipation. The other formulas may be appropriate in the elderly, depending on other patient-specific characteristics, However, concentrated formulas rarely contain fiber and may exacerbate the constipation, high protein formulas are unlikely to impact constipation unless are fiber-containing, and elemental formulas are not indicated for constipation, and may exacerbate the problem if are fiber-free.

Question 21

An assessment of functional status may aid in determining nutrition risk. Which of the following provides an assessment of functional status?

1: Intelligence quotient exam
2: Handgrip strength assessment
3: Measurement of fat mass
4: Visual exam

Answer 21

2: Handgrip strength assessment

Impaired functional status is defined as the inability to perform activities necessary for routine self-care. Handgrip strength is a measurement that may indicate functional ability. A sedentary lifestyle in older adults predisposes them to the risk of malnutrition, decline of functional status, and development of chronic diseases.

Question 22

Which of the following vitamin considerations is most important in an older adult receiving a total nutrient admixture (3-in-1) parenteral nutrition (PN) as well as anticoagulation (Warfarin) therapy?

1: Vitamin K
2: Vitamin E
3: Vitamin C
4: Vitamin B1

Answer 22

Vitamin K

Vitamin K is in adult multivitamin formulations. Vitamin K is also found in lipid emulsions. Vitamin K can partially reverse the effects of Warfarin. The INR should be monitored closely with transitioning on or off PN in patients on Warfarin.

Question 23

Enteral nutrition formulas supplemented with fiber are often used in the older adult to prevent constipation. Which of the following considerations is most important if this type of formula is chosen?

1: Addition of a prokinetic agent
2: Avoidance of lactose
3: Lowering feeding rate to prevent bloating
4: Provision of adequate water

Answer 23

4: Provision of adequate water

Constipation is a common problem in the elderly. For patients requiring long-term enteral feedings, a formula that contains fiber is often helpful to prevent constipation; however, the provision of adequate water is required when using these products in order to prevent adverse gastrointestinal effects. Often, the presence of fiber and fluid will be adequate to maintain adequate bowel movements and a prokinetic agent will not be required. All enteral products are lactose free. Lowering the rate of the enteral feeding may be required in short term periods to prevent bloating, but this would not be a long term solution to prevent adverse gastrointestinal effects.

Question 23

Enteral nutrition formulas supplemented with fiber are often used in the older adult to prevent constipation. Which of the following considerations is most important if this type of formula is chosen?

1: Addition of a prokinetic agent
2: Avoidance of lactose
3: Lowering feeding rate to prevent bloating
4: Provision of adequate water

Answer 23

4: Provision of adequate water

Constipation is a common problem in the elderly. For patients requiring long-term enteral feedings, a formula that contains fiber is often helpful to prevent constipation; however, the provision of adequate water is required when using these products in order to prevent adverse gastrointestinal effects. Often, the presence of fiber and fluid will be adequate to maintain adequate bowel movements and a prokinetic agent will not be required. All enteral products are lactose free. Lowering the rate of the enteral feeding may be required in short term periods to prevent bloating, but this would not be a long term solution to prevent adverse gastrointestinal effects.

Question 24

Which of the following is most likely to be observed first, for a patient with no history of diabetes who is overfed?

1: Hepatobiliary effects
2: Hyperglycemia
3: Weight gain
4: Accumulation of carbon dioxide

Answer 24

Hyperglycemia

Overfeeding of energy can have a plethora of negative effects on a patient’s clinical condition. All of the answers are potential effects of overfeeding; however, hyperglycemia is likely the first of the effects to occur. While the etiology of the hyperglycemia will need to be determined, this observation could possibly indicate overfeeding.

Question 25

Which of the following is most likely to occur as the result of an age-related functional change in the gastrointestinal (GI) tract?

1: Increased anorectal tone
2: Decreased vitamin A absorption
3: Increased calcium absorption
4: Decreased gastric emptying

Answer 25

Functional age-related changes in the GI tract may include an altered GI motility, such as delayed gastric emptying. The changes may include altered sensory response; decreased muscle mass, strength, or pressure; decreased secretions. The absorption of certain nutrients, such as calcium, iron, vitamin D, and others may be reduced. With aging, liver values of vitamin A remain stable, which may mean that, despite decreasing dietary intake, absorption of the vitamin increases.

Question 26

The Plan/Do/Study/Act (PDSA) cycle is employed as a

1: quality improvement problem-solving model.
2: medical nutrition protocol.
3: tool for measuringhand grip strength among institutions.
4: benchmarking tool for standardizing days of TPN therapy to compare institutions.

Answer 26

Quality improvement problem solving model

The Plan/Do/Study/Act (PDSA) cycle is a quality improvement problem-solving model. The process begins with a planning phase, followed by the implementation of a process improvement (the “do” phase). The study process measures the results of the improvement effort. During the “act” phase, the team will determine if changes made should be permanent and includes standardization and documentation of the processes.

Question 27

Which of the following medication classes used in the older adult population will LEAST likely contribute to anorexia?

1: Narcotic analgesics
2: Antihistamines
3: Histamine receptor antagonists
4: Antihypertensive agents

Answer 27

2: Antihistamines

A number of medications can cause anorexic effects, and these effects may be more pronounced in the older adult. Narcotic analgesics, histamine receptor antagonists, and antihypertensive agents may cause secondary effects of anorexia.

Question 28

A patient receiving digoxin and parenteral nutrition who is experiencing signs of digoxin toxicity should be assessed for

1: hypokalemia.
2: hypocalcemia.
3: hypermagnesemia.
4: hypophosphatemia.

Answer 28

1: hypokalemia.

Digoxin has a narrow therapeutic range. In patients with hypokalemia or hypomagnesemia, digoxin toxicity may occur despite therapeutic concentrations because depletion of potassium of magnesium will sensitize the myocardium to digoxin.

Question 29

An older adult with poor oral intake over a two month period requires specialized nutrition support. Which of the following electrolyte abnormalities is associated with aggressive nutrition support?

1: Hyperkalemia
2: Hypocalcemia
3: Hypermagnesemia
4: Hypophosphatemia

Answer 29

Hypophosphatemia

The main pathophysiologic features of the refeeding syndrome are abnormalities of fluid balance, glucose metabolism, vitamin deficiency, and electrolyte imbalance. Hypophosphatemia, hypomagnesemia, and hypokalemia are common metabolic derangements seen in refeeding. Hypophosphatemia is considered the hallmark feature of refeeding syndrome.

Question 30

In which of the following older adult populations is toxicity with fat soluble drugs most likely?

1: Obese
2: Sedentary
3: Malnourished
4: Physically active

Answer 30

1: Obese

Body composition is an important determinant of drug response. Distribution of fat soluble drugs is increased in the obese older adult because the proportion of adipose tissue to lean body mass is increased in these individuals. Prolonged clearance and increased potential toxicity may result from excessive accumulation in adipose tissue.

Question 31

The Short-Form Mini-Nutritional Assessment (MNA-SF) was derived from the Mini-Nutritional Assessment (MNA) in order to

1: adapt the MNA for use in pediatric patients.
2: eliminate the need to obtain height and weight data for nutrition assessment.
3: allow patients to generate their own nutrition assessment with a questionnaire method.
4: obtain high diagnostic accuracy for detecting nutritional problems in older adults with a brief screening tool.

Answer 31

4: obtain high diagnostic accuracy for detecting nutritional problems in older adults with a brief screening tool.

The Mini Nutritional Assessment (MNA) is a nutrition screening and assessment tool that allows providers to identify elderly (age 65 and above) patients who are malnourished or at risk of malnutrition. The MNA was developed more than 20 years ago, and it originally consisted of 18 questions. The MNA-Short Form is now the preferred version of this tool because of its streamlined 6 question form that still retains the validity and accuracy of the original MNA.

Question 32

Which of the following is NOT a component of the Comprehensive Geriatric Assessment tool?

1: Exercise level
2: Anthropometry
3: Quality of life
4: Biochemical markers

Answer 32

Exercise Level

Nutrition is an important determinant of the quality of aging. As part of the CGA nutrition assessment may include the assessment of anthropometric measurements, biochemical markers, and medications.

Question 33

JD is an 85 year old male whose height is 63 inches and weight is 45kg. Ten years ago his weight was 55kg. His weight loss has been non-volitional and gradual, and he has no major health problems or changes in oral intake. Which of the following statements most appropriately describe JD’s weight loss?

1: JD demonstrates a decrease in lean body mass known as sarcopenia, which occurs during the aging process.
2: JD’s weight loss is not a normal phenomenon. He should be evaluated for an underlying disease process.
3: JD demonstrates a decrease in fat mass, which occurs with the aging process.
4: JD should be placed on a specialized nutrition support regimen to replace the weight he has lost.

Answer 33

1: JD demonstrates a decrease in lean body mass known as sarcopenia, which occurs during the aging process.

Sarcopenia is the loss of lean body mass and function that is normal in the aging process. Non-volitional weight loss over a few months may indicate an underlying disease process, but when it occurs over a longer period of time, as a process of aging, it may not herald a disease process. Fat redistribution occurs with aging, but the primary loss is due to loss of lean body mass. Specialized nutrition support is indicated if the weight loss is associated with a disease process or if compromised gastrointestinal function is present.

Question 34

What is the most widely used tool to measure generic health-related quality of life?

1: Katz ADL
2: Lawton-Brody IADL
3: FIM
What is the most widely used tool to measure generic health-related quality of life?

1: Katz ADL
2: Lawton-Brody IADL
3: FIM
4: SF-36

Answer 34

4: SF-36

The SF-36 is one of the most widely used tools to measure health-related quality of life. The Katz ADL (Katz Index of Independence in Activities of Daily Living) tool measures activities of daily living and Lawton-Brody’s IADL (Lawton-Brody Instrumental Activities of Daily Living Scale) tool measures instrumental activities of daily living. The FIM (Functional Independence Measure) is a tool used to measure functional independence in rehabilitation settings.

Question 35

Which of the following is not a common change in the body composition of healthy older adults?

1: Increased body water
2: Decreased bone mineral mass
3: Decreased lean body mass
4: Redistributed fatty tissue

Answer 35

1: Increased body water

Over time, older adults experience decreased bone mineral mass, decreased lean body mass, redistribution of fat, and a decrease in total body water.

Question 36

Sarcopenia, the loss of lean body mass that occurs with aging, is also associated with

1: excess growth hormone.
2: decreased cytokine activity.
3: decreased bone density.
4: decreased total body fat.

Answer 36

3: decreased bone density.

Sarcopenia is a common condition among adults over the age of 65 years and increases with age. Functional disability, falls, and decreased bone density, in addition to glucose intolerance, and decreased heat and cold tolerance have been linked to sarcopenia. Decreased physical activity, malnutrition, increased cytokine activity, oxidative stress, and abnormalities in growth hormone (decreased growth hormone production) have been implicated in the etiology of sarcopenia. Many older persons also experience an increase in total body fat.

Question 37

Which of the following best describes sarcopenia that contributes to a decrease in energy related requirements?

1: Decreased fat mass and increased lean body mass
2: Increased fat mass and decreased lean body mass
3: Increased fat mass and increased lean body mass
4: Decreased fat mass and decreased lean body mass

Answer 37

Increased fat mass and decreased lean body mass

On average, adult energy needs decline an estimated 5 percent per decade. One reason is that people usually reduce their physical activity as they age, although they need not do so. Another reason is that lean body mass diminishes, slowing the basal metabolic needs. The lower energy expenditure of older adults requires that they eat less food to maintain their weights. Accordingly, the energy RDA for adults decreases slightly after age 50.

Question 38

When using cyclic parenteral nutrition (PN) solutions for nonstressed patients, age may be an important factor in monitoring for complications because older adults have

1: higher rates of insulin resistance and hyperglycemia.
2: lower fat and glucose oxidation
3: higher fluid requirements.
4: lower concentrations of free fatty acids.

Answer 38

1: higher rates of insulin resistance and hyperglycemia.

Aging has been associated with alterations in substrate use metabolism. Glucose oxidation decreases as age increases and can impact tolerance during cyclic parenteral nutrition, potentially resulting in hyperglycemia as PN is cycled. The decreased glucose oxidation is possibly the result of higher insulin resistance with advancing age. Increased fat oxidation has been correlated with increased age. Older adults have been found to have higher concentrations of free fatty acids compared to that of middle-aged patients, which suggests that as age increases so does mobilization of free fatty acids from adipose tissue. Fluid requirements are generally lower in older adults due to lower lean body mass tissue available for fluid storage, and potential need for fluid restriction may be higher in this population.

Question 39

What is the recommended daily energy intake for patients over 60 who are receiving hemodialysis or peritoneal dialysis?

1: 25 kcal/kg on nondialysis days and 35 kcal/kg on dialysis days
2: 30-35 kcal/kg
3: 35 kcal/kg on nondialysis days and 25 kcal/kg on dialysis days
4: 40-45 kcal/kg

Answer 39

2: 30-35 kcal/kg

Metabolic balance studies of people undergoing maintenance hemodialysis indicate that the total daily energy intake of 35 kcal/kg/d induces neutral nitrogen balance and is adequate to maintain serum albumin and anthropometrics indices. Because individuals more than 60 years of age tend to be more sedentary, a total energy intake of 30-35 kcal/kg is acceptable, according to the National Kidney Foundation’s Kidney Disease Outcomes Quality Initiative guidelines.

Question 40

A 65 year old female had complications associated with GI surgery, and was admitted to the intensive care unit with pneumonia and septic shock. After she became hemodynamically stable, she was started on parenteral nutrition secondary to a prolonged ileus. Prior to surgery, she was at her ideal weight. Currently her labs include albumin 2.0 mg/dL and creatinine 1.0 mg/dL. Her urine output is adequate. Which of the following best estimates her protein needs for initiation of parenteral nutrition therapy?

1: 0.6 grams/kg
2: 0.8 grams/kg
3: 1.5 grams/kg
4: 2.5 grams/kg

Answer 40

3: 1.5 grams/kg

Protein requirements can be estimated initially and adjusted based on nitrogen balance studies and clinical response. While her protein needs will be influenced by her age, her renal function is adequate and she will require and can tolerate higher amounts of protein due to her stress level. Her degree of stress warrants 1.5 grams/kg of protein. Negative acute phase protein status reflects inflammatory rather than nutritional status.

Question 41

In a 100 kg afebrile person with intact skin, insensible fluid loss from lungs and skin is approximately

1: 500 mL/day.
2: 800 mL/day.
3: 1000 mL/day.
4: 1200 mL/day.

Answer 41

3: 1000 mL/day.

Water output from the feces, skin, and lungs is considered insensible loss and can account for up to 1L of fluid loss per day.

Question 42

An 87-year-old woman underwent a total abdominal colectomy. Her ileostomy output is 1.5-2.0 liters per day. Supplementation of which of the following micronutrients should be considered?

1: Zinc
2: Copper
3: Vitamin E
4: Chromium

Answer 42

Zinc

Older adult patients are at an increased risk of zinc deficiency at baseline primarily due to decreased intake and absorption. The management of high output ileostomy (>1 L/d) should include fluid replacement that approximates the electrolyte composition of ileal fluid. The insult of recent surgery and the patient’s output losses via her ostomy will increase her risk of zinc deficiency.

Question 43

A decrease in food intake in older adults is most likely attributable to

1: decreased taste and flavor sensations.
2: age-related decreases in stomach capacity.
3: fear of stool or flatus incontinence.
4: enhanced olfaction sensation.

Answer 43

1: decreased taste and flavor sensations.

A decrease in food intake in older adults is usually attributed to changes in taste and flavor sensations. Older adults may also exhibit decreased hunger and early satiety, which also contribute to decreased oral intake. Fear of incontinence typically interferes with fluid intake rather than food intake. Older adults, particularly women, with reduced olfaction (sense of smell) have a reduced interest in cooking and consuming a variety of foods, thereby potentially resulting in reduced oral intake.

Question 44

A 68 year old woman with a history of cirrhosis is receiving enteral nutrition due to recent gastrointestinal surgery. She has worsening hepatic encephalopathy. Which of the following should be tried first?

1: Decrease in protein provision to 0.6 g/kg/d
2: Formula high in medium chain triglyceride content
3: Formula enriched with branched-chain amino acids
4: Lactulose and rifaximin therapy

Answer 44

Lactulose and rifaximin therapy

The first step in treating hepatic encephalopathy is lowering blood ammonia concentrations with medications, such as lactulose and/or rifaximin. It is recommended that patients with cirrhosis receive 1-1.5 g protein/kg/d to prevent muscle catabolism and promote gluconeogenesis. A temporary protein restriction (0.6-0.8 g protein/kg/d) may be indicated if the patient fails to respond to medical management or until the cause of encephalopathy can be identified and eliminated. Benefits of branched-chain amino acid (BCAA) enriched formula are still debated, but may be considered for patients with severe encephalopathy who have not responded to aggressive medical therapy.

Question 45

An 80 year old man, living alone at home, has experienced a 15 lb unintentional weight loss over the last year and a half. The clinician assessing his nutrition status finds that he has inadequate intake. Which of the following is LEAST likely to contribute to his weight loss?

1: Decreased taste sensation
2: Social isolation
3: Food sensitivities
4: Polypharmacy

Answer 45

3: Food sensitivities

Decreased oral intake by older adults can be related to multiple causes. Older adults often have multiple chronic medical conditions that require altered dietary intake and use of numerous medications which can impair food intake or alter digestion, absorption, metabolism and excretion. Additional potential barriers to eating include social isolation, economic hardships, decreased functional capacity related to shopping for or preparing foods, dementia, loss of taste and smell, and difficulty chewing and swallowing.

Question 46

An 85 year old nursing home resident was transferred to the hospital with anorexia, malnutrition, and probable aspiration pneumonia. Which of the following nutrition plans would be most appropriate for this patient?
1: Start the patient on a regular oral diet with supplements
2: Establish central access with a peripherally inserted central catheter (PICC) line and initiate parenteral feedings
3: Establish peripheral access and initiate peripheral parenteral nutrition until enteral feedings can be established
4: Determine the most appropriate enteral feeding route and establish tube feeding

Answer 46

4: Determine the most appropriate enteral feeding route and establish tube feeding

The most appropriate intervention is to provide enteral feedings. Since there is no evidence of compromised gastrointestinal function, parenteral nutrition is not indicated. Transitioning to an oral diet with supplements may be appropriate once safety of oral intake is established.

Question 47

Levodopa is often used in the treatment of Parkinson Disease. Which of the following vitamins has been demonstrated to reverse the effects of levodopa?
1: Vitamin B6
2: Vitamin B12
3: Vitamin C
4: Vitamin K

Answer 47

1: Vitamin B6

Pyridoxine (vitamin B6) has been shown to reverse the effects of levodopa by increasing the rate of aromatic amino acid decarboxylation. Patients who require this medication, such as patients with Parkinson Disease, should use care in selecting foods or vitamin supplements that may contain vitamin B6. These foods should not necessarily be eliminated, but should possibly be restricted below usual recommendations.

Question 48

Which of the following is evidenced by a gradual wasting of body fat and somatic muscle with preservation of visceral proteins?

1: Marasmus
2: Mixed state
3: Kwashiorkor
4: Hypoalbuminemia

Answer 48

Marasmus

Marasmus is a gradual wasting of body fat and somatic muscle with preservation of visceral proteins. This condition may be seen in chronic illness and prolonged starvation, as well as in the elderly and the patient with anorexia nervosa. Kwashiorkor is associated with visceral protein wasting, causing hypoalbuminemia, with preservation of fat and somatic muscle. Mixed state is a combination of marasmus and kwashiorkor.