Considerations of Nutrition Support in Older Adults Flashcards
The SF-36 is one of the most widely used tools to measure ___-related ___ ___ ___.
-Health related
-Quality of life
What does the Katz ADL tool measure?
Activities of daily living
What does the lawton-Brody’s IADL tool measure?
Instrumental activities of daily living.
What is the FIM is a tool used to measure?
Functional independence in rehabilitation settings
A 25(OH)D value between ___-___ ng/mL signifies vitamin D insufficiency
21-29
A 25(OH)D value < ___ ng/mL indicates deficiency.
20
A 25(OH)D level ≥___ ng/mL indicates adequate vitamin D stores.
30
What is frailty described as?
A multifactorial syndrome with various phenotypes that affects quality of life, vulnerability, and disability in older adults.
What is a hallmark of frailty?
Loss of muscle mass and strength typical of sarcopenia.
List the criteria for diagnosing frailty.
- Unintentional weight loss (10 pounds in past 1 year)
- Self-reported exhaustion
- Weakness (hand-grip strength)
- Slow walking speed
- Low physical activity
What role do inflammation of chronic disease, nutrition status, and oxidative stress play in frailty?
They contribute to frailty.
Fill in the blank: A diagnosis of frailty can be made when _______ additional criteria are met.
3 or more
How many parenteral multivitamin products are currently available for adults?
Two
What are the two types of parenteral multivitamin products available for adults?
One with vitamin K and one without
Do both parenteral multivitamin products meet FDA mandates?
Yes
In addition to parenteral multivitamins, where else is vitamin K found?
Lipid emulsions
What should be monitored closely in patients receiving both PN and warfarin?
INR
True or False: Warfarin therapy is a contraindication to provision of a multivitamin product with vitamin K.
False
Vitamin K can impact the effects of which anticoagulation therapy?
Warfarin
What are the three levels of activities of daily living used to assess an older adult’s functional status?
- Basic activities of daily living (BADLs)
- Instrumental or intermediate activities of daily living (IADLs)
- Advanced activities of daily living (AADLs)
These levels help in evaluating the functional capabilities of older adults.
What do BADLs refer to?
Self-care tasks such as grooming and maintaining continence
BADLs are essential for personal hygiene and basic self-maintenance.
What do IADLs refer to?
The ability to maintain an independent household, such as taking medications
IADLs are crucial for managing daily life and ensuring independence.
What are AADLs?
Activities that include fulfilling societal, community, and family roles as well as participating in recreational or occupational tasks such as exercising
AADLs focus on more complex social and personal activities.
True or False: AADLs include recreational activities.
True
How is “impaired functional status” defined?
The inability to perform activities necessary for routine self-care
Handgrip strength is a measurement that may indicate ____ ability
Functional
A sedentary lifestyle in older adults predisposes them to the risk of ___, decline of ___ status, and development of ___ diseases.
-Malnutrition
-Functional
-Chronic
What is a decrease in food intake in older adults usually attributed to?
Changes in taste and flavor sensations.
Older adults may exhibit decreased hunger and early satiety, which also contribute to decreased oral intake.
Fear of incontinence typically interferes with ___ intake
Fluid
Older adults, particularly women, with reduced ___ have a reduced interest in cooking and consuming a variety of foods, thereby potentially resulting in reduced oral intake.
Olfaction
What is the Mini Nutritional Assessment (MNA)?
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. It was developed over 20 years ago and consisted of 18 questions.
Why is the MNA-Short Form preferred of the MNA?
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.
What is digoxin prescribed for?
Arrhythmias and coronary heart disease
Digoxin is often paired with diuretics in certain patient populations.
How is digoxin eliminated from the body?
Solely via renal excretion
What are some risk factors associated with digoxin toxicity?
- Renal insufficiency
- Hypokalemia
- Hypomagnesemia
- Hypercalcemia
- Advanced age
Potassium depletion sensitizes the ____ to digoxin.
Myocardium
What effect do electrolyte abnormalities have in relation to digoxin?
They can cause arrhythmias and lead to toxicity despite therapeutic concentrations.
Is a DNR or DNAR order a contraindication to the provision of AANH?
No
What should the medical team explain to a patient with a DNR or DNAR order?
All other medically appropriate care will still be provided, apart from the decline resuscitative interventions.
AANH can be _______ or withdrawn in patients with a DNR or DNAR if all concerned agree.
withheld
What does PDSA stand for?
Plan/Do/Study/Act
What occurs during the ‘do’ phase of PDSA?
Implementation of a process improvement
What is measured during the ‘study’ phase of PDSA?
Results of the improvement effort
What does the ‘act’ phase of PDSA involve?
Determining if changes should be permanent and standardization/documentation of processes
The PDSA cycle begins with the _______ phase.
Planning
What is the primary purpose of the PDSA cycle?
To improve healthcare quality
Aging has been associated with alterations in ___ use metabolism.
Substrate
How does glucose oxidation change with age?
Glucose oxidation decreases as age increases
What impact can decreased glucose oxidation have during cyclic parenteral nutrition?
It can impact tolerance, potentially resulting in hyperglycemia
What is a possible reason for decreased glucose oxidation in older adults?
Higher insulin resistance with advancing age
What change in fat oxidation is observed with increased age?
Increased fat oxidation
What have studies found about free fatty acid concentrations in older adults compared to middle-aged patients?
Older adults have higher concentrations of free fatty acids
What does higher free fatty acid concentration suggest about adipose tissue in older adults?
Increased mobilization of free fatty acids from adipose tissue
How do fluid requirements change in older adults?
Fluid requirements are generally lower
What contributes to lower fluid requirements in older adults?
Lower lean body mass tissue available for fluid storage
What are advance directives?
Documents that allow individuals to document their treatment preferences and identify a surrogate or proxy decision maker.
What is a nutrition component of some advance directives?
Use or nonuse of artificially administered nutrition and hydration.
True or False: Advance directives can only address life sustaining treatment.
False
What happens when an incompetent person’s previously expressed wish is known?
It must be honored by a surrogate decision-maker if it meets state evidentiary standards.
Why causes pulmonary aspiration
Pulmonary aspiration may result from reflux of gastric contents or oral secretions
What is (on of) the most serious complications of EN which can result in pneumonia or death?
Pulmonary aspiration
How does sarcopenia/frailty lead to aspiration?
Sarcopenia and frailty’s age-related decline in muscle strength may affect the smaller striated muscles of the head and neck, therefore contributing to dysphagia and aspiration.
What does MDS stand for?
Minimum Data Set
What is the purpose of the MDS?
To assess all aspects of clinical status and facilitate problem identification in residents of long-term care facilities
In which section of the MDS is the nutrition component found?
Section K
What aspects of nutrition does Section K assess?
Height and weight, weight changes, swallowing disorders, and nutrition approaches
What types of diets are included in the nutrition approaches of Section K?
Mechanically altered diets, therapeutic diets, and artificial nutrition and hydration
What does CAA stand for?
Care Area Assessment
What does the Care Area Assessment (CAA) investigate?
Trigger areas identified through the MDS to determine if further planning and intervention is required
What do the MDS and CAA form together?
Residential Assessment Instrument (RAI)
Who mandates the use of the RAI in long-term care facilities?
Center for Medicare and Medicaid (CMS)
What is the RAI used for?
As a screening and assessment tool for resident assessments and identification of problems
What must be developed for problems identified through the RAI?
Individualized care plans
Fill in the blank: The nutrition component of the MDS assesses a resident’s ability to maintain adequate _______.
nutrition and hydration
Why is it important for family members to be educated about decreased food/fluid intake during the dying process?
To understand the changes in nutritional needs and the experience of eating as illness advances.
Education helps family members support patients appropriately during the dying process.
What happens to nutritional needs as illness advances?
Fewer calories are needed due to changes in the patient’s condition.
This reflects the body’s natural decline in function as death approaches.
Do dying patients typically feel hungry or thirsty?
No
This is due to the natural process of dying shutting down normal bodily functions.
Nutrition interventions for the elderly are often more conservative and focus on optimizing ___ nutritional intake first.
Oral
When is liberalization of diet not indicated for elderly patients?
When the patient needs a modified texture and thickened liquid diet.
What should be offered to patients if PO diet liberalization is not indicated?
Food preferences, fortified foods, and oral nutrition supplements.
Why is Medicare coverage unlikely for nutrition support supplies in certain patients?
Because the patient can consume nutrition by mouth.
Why are short-term nasogastric tubes generally not recommended in elderly populations?
Due to the increased risk of aspiration and hindrance on swallow function.
What may help minimize constipation in the tube fed, elderly patient?
A fiber-containing formula
Fiber aids in promoting bowel movement and waste propulsion.
What is the minimum fluid requirement when adding fiber to the enteral regimen?
1 mL of fluid per kcal
This helps prevent solidification of waste in the colon.
What type of formula may exacerbate constipation?
2 kcal/mL concentrated formula
These formulas typically contain less free water and fiber.
Are semi-elemental and elemental formulas indicated for constipation?
No
These types of formulas are not suitable for managing constipation.
What is (often) the first of overfeeding?
Hyperglycemia
Name some complications of home EN?
- Decreased urination
- Tube clogging
- Tube leaking
- Skin problems at tube site
What is the most common complication in a group of elderly patients receiving home enteral nutrition?
Decreased urination
What does decreased urination indicate in tube fed patients?
Inadequate fluid intake
Decreased urination on enteral feedings may cause complications like ____ and risk for ____ ___ ___.
-Dehydration
-Acute kidney injury
In the extra-cellular fluid volume depleted patient, the urine becomes concentrated and contains very little ___ consequent to renal conservation of ___ and ___.
-Sodium
-Salt and water
In the dehydrated patient, although urine is concentrated (due to water absorption in the distal tubule), urinary Na+ is not ____.
Decreased
What increases the risk of developing vitamin B12 deficiency?
Decline in gastric acid production with age and use of acid lowering medications
Acid lowering medications include H2 blockers and PPIs.
What process is required for vitamin B12 bound to food to be absorbed?
Release from protein, which requires the presence of gastric acid
What molecule does vitamin B12 bind with after being released from protein?
Intrinsic factor
Where is vitamin B12 absorbed in the body?
In the small intestine
What medications have been associated with vitamin B12 deficiency (among older adults)?
Use of H2 blockers and PPIs, especially with prolonged PPI use
Even when supplemented with oral B12-containing vitamins.
What type of feedings are preferred in patients at increased risk for aspiration?
Small bowel feedings
Small bowel feedings help reduce the risk of aspiration.
Why would a GJ tube preferred over a nasojejunal tube?
Provides long-term access
It is the best plan for preventing aspiration in the long-term.
What are some contraindications for GJ tube placement?
History of bowel necrosis, severe ascites, peritonitis, abdominal wall infection
These conditions could complicate the placement of a GJ tube.
What are the most common causative agents associated with diuretic-induced hyponatremia?
Thiazide or thiazide-like diuretics
What effect do loop diuretics have on anti-diuretic hormone-induced free water absorption?
They can diminish it
What is an example of a loop diuretic?
Furosemide
What condition can loop diuretics treat in relation to anti-diuretic hormone?
Hyponatremia in syndrome of inappropriate antidiuretic hormone
What is sarcopenia?
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 ____, it may not herald a disease process. Fat redistribution occurs with ____
-Aging
-Aging
Nutrition support is indicated if the weight loss is associated with a ___ process or if compromised ___ function is present.
-Disease
-Gastrointestinal
Over time, older adults experience ___ bone mineral mass
Decreased
Over time, older adults experience ____ lean body mass
Decreased
Over time, older adults experience ____ of fat
Redistribution
Over time, older adults experience a ___ in total body water.
Decrease
What are the calorie needs for stable patients under 65-years of age on maintenance HD according to KDOQI?
35 kcal/kg
This is based on the guidelines from the National Kidney Foundation’s Kidney Disease Outcomes Quality Initiative.
What are the calorie needs for stable patients older than 65-years of age on maintenance HD according to KDOQI?
30 to 35 kcal/kg
This recommendation is also from the KDOQI guidelines.
What are the main pathophysiologic features of refeeding syndrome?
Abnormalities of fluid balance, glucose metabolism, vitamin deficiency, and electrolyte imbalance.
These features can lead to serious complications if not recognized and managed appropriately.
What is the hallmark feature of refeeding syndrome?
Hypophosphatemia.
Hypophosphatemia is a significant indicator that can help in diagnosing refeeding syndrome.
Which common metabolic derangements are seen in refeeding syndrome?
Hypophosphatemia, hypomagnesemia, and hypokalemia.
These electrolyte imbalances can contribute to various clinical manifestations.
What are some consequences linked to sarcopenia?
Functional disability, falls, decreased bone density, glucose intolerance, decreased heat and cold tolerance.
These consequences can significantly affect the quality of life in older adults.
What factors have been implicated in the etiology of sarcopenia?
- Decreased physical activity
- Malnutrition
- Increased cytokine activity
- Oxidative stress
- Abnormalities in growth hormone (decreased growth hormone production)
These factors contribute to the development and progression of sarcopenia.
What syndrome is associated with long-term alcohol abuse and vitamin B1 deficiency?
Wernicke-Korsakoff syndrome
Wernicke encephalopathy is also part of this syndrome.
Which vitamins’ and mineral absorption and utilization can be affected by regular alcohol intake?
THIAMINE
Vitamins:
1. Vitamin B6 (pyridoxine)
2. Vitamin B12 (cyanocobalamin)
3. Vitamin B9 (folic acid)
4. Vitamin C
5. Vitamin A
6. Vitamin E
7. Vitamin D
Minerals:
1. Iron
2. Zinc
True or False: Frank deficiency is more common with thiamin compared to other vitamins due to alcohol abuse.
True
What are some factors that contribute to decreased oral intake in older adults?
Multiple chronic medical conditions, dietary restrictions, numerous medications, social isolation, economic hardship, decreased functional capacity, dementia, loss of taste and smell, difficulty chewing or swallowing
These factors can impair food intake or alter nutrient digestion, absorption, metabolism, and/or excretion.
How can chronic medical conditions affect older adults’ food intake?
They can require dietary restrictions and lead to the use of numerous medications.
These medications may impair food intake or alter nutrient digestion and absorption.
How do GI changes with aging cause decreased hunger?
Gastrointestinal changes with aging include “decreased velocity of neuronal conduction to GI tract causing decreased hunger sensations
What sensory changes may occur in aging that affect the gastrointestinal system?
Decrease in taste and smell.
What happens to saliva production as one ages?
Decreased saliva.
What change occurs in the oropharyngeal phase of swallowing with aging?
Increased oropharyngeal phase.
What happens to the esophageal sphincter with aging?
Delayed opening of the esophageal sphincter, along with delayed opening of the esophageal sphincter, and decreased peristaltic pressure in the esophagus.
What gastrointestinal changes occur in the stomach with aging?
- Increased and more rapid satiety
- Reduced peristalsis
- Gastric contractile force increase
- Increase in gastric pH
How does aging affect the absorption of carbohydrates and proteins?
Decreased absorption.
What vitamins show decreased absorption in the intestines with aging?
- Folate
- Vitamins B12 and D
- Calcium
Which vitamins/nutrients see increased absorption in older adults?
- Vitamins A and C
- Cholesterol
What changes occur in the lower intestines with aging?
- Decreased rectal wall elasticity
- Decreased colonic motility
- Constipation
What is the percentage reduction in hepatic blood flow in the elderly?
35%
This reduction is accompanied by decreased hepatic volume.
By what percentage does hepatic volume reduce in men and women by the age of 91?
28% in men and 44% in women
This reduction affects drug metabolism.
What is the percentage reduction in glomerular function (GFR) per decade after age 40?
6-10%
This indicates a significant decline in renal function as one ages.
By the age of 90, what is the estimated reduction in overall renal function?
30-40%
This reflects the cumulative effects of aging on kidney function.
What do numerous studies report about dying patients’ electrolyte values?
Patients have abnormal electrolyte values.
The analgesic theory suggests that starvation boosts the production of _______.
[ketones]
List some life-threatening symptoms caused by aggressive AANH.
- Edema
- Ascites
- Nausea
- Vomiting
- Pulmonary congestion
What trend has been observed in the number of malnutrition diagnoses among older adults in hospital settings?
The number of diagnoses has increased from previous years.
What effect do antibiotics have on stool consistency?
Antibiotics commonly cause loose stool by decreasing beneficial microbiota within the GI tract.
What risk is associated with antibiotic use in relation to C. difficile?
Some antibiotics may increase the risk of C. difficile overgrowth.
What is the effect of codeine on gastrointestinal motility?
Codeine may actually decrease GI motility and contribute to constipation.
What condition may long term use of opioids lead to?
Long term use of opioids may contribute to overflow diarrhea where liquid stool flows around stool blockage.
Fill in the blank: Medications that induce a hyperosmolar environment include those that contain _______.
magnesium or sorbitol
Older adults have increased metabolic complications associated with PN therapy due to insulin ___, impaired ___ and ___ functions and ____ deficiencies.
-Resistance
-Renal
-Cardiac
-Micronutrient
What is the primary reason older adults are at an increased risk of zinc deficiency?
Decreased oral intake and absorption
This highlights the challenges older adults face in maintaining adequate nutrition.
How is zinc primarily eliminated from the body?
Fecal excretion
Understanding the elimination pathways is important for assessing zinc status.
What is the recommended zinc intake for each liter of GI output?
12 mg zinc
This recommendation is crucial for managing patients with gastrointestinal losses.
What is the standard oral adult replacement dose of zinc sulfate?
220 mg twice daily (100 mg total of elemental zinc per day)
This dosage is used to correct zinc deficiency in adults.
Do serum zinc levels always reflect total body stores?
No
This can complicate the assessment of zinc status in patients.
What adverse effects are associated with excessive zinc supplementation beyond 2–3 weeks?
Copper and iron deficiencies
This is due to competitive antagonism of enteric transport proteins and metalloenzymes.
What health issues can chronic supplementation with higher doses of zinc (>20 mg/d) cause?
Microcytosis, neutropenia, decreased HDL cholesterol
These conditions highlight the importance of monitoring zinc intake.
Which nutrients are excreted via urine output?
Choline, chromium, thiamin
This indicates the body’s handling of certain vitamins and minerals.
Water lost from the skin and lungs is considered ___ losses and can account for up to 1000 mL (1L) of fluid loss per day under normal conditions of body and ambient temperature.
insensible losses
Insensible losses can account for up to ___ mL of fluid loss per day under normal conditions of body and ambient temperature.
1000
List some areas of the body where vitamin D receptors are found.
- Parathyroid glands
- Muscle tissue
- Cardiovascular system
- Kidneys
What happens when vitamin D does not bind to VDRs?
- Increased PTH production
- Decreased stimulation of muscle fibers
- Increased renin activity
- Potential for hyperlipidemia
Without vitamin D binding to VDRs, _______ production is increased.
PTH
Decreased stimulation of muscle fibers due to lack of vitamin D binding leads to _______.
muscle weakness
True or False: Vitamin D deficiency can lead to hypertension.
True
What is the role of vitamin D in lipid cell membranes?
It is needed for lipid cell membranes formation
This highlights the importance of vitamin D in cellular health.
What are the four ethical principles in healthcare?
Autonomy, beneficence, nonmaleficence, and justice
These principles guide ethical decision-making in healthcare.
Define autonomy in the context of healthcare ethics.
Respecting and upholding the patient’s right to self-determination
Autonomy is crucial for patient-centered care.
How should the principle of autonomy be applied when making decisions for an incompetent individual?
It should guide the health care team in making decisions based on the individual’s advance directive regarding artificial nutrition and hydration
Advance directives express a patient’s wishes about medical treatment.
What is beneficence?
An ethical principle whereby health care providers actively seek the good of the patient above all other priorities
Beneficence emphasizes positive actions for patient welfare.
Define nonmaleficence.
“To do no harm”; relates to preventing, minimizing, and relieving needless suffering and pain
Nonmaleficence is a fundamental principle to avoid harm to patients.
What is the principle of justice in healthcare?
Fair distribution of resources
Justice ensures equitable access to healthcare services.
The ethical principle that emphasizes preventing harm is called _______.
nonmaleficence
True or False: Beneficence and nonmaleficence become more central when an advance directive is not available.
True
In the absence of clear patient directives, these principles guide care.
What are common causes of constipation?
Dehydration and either inadequate or excessive fiber intake
Identifying the cause is crucial for effective treatment.
True or False: Excessive fiber intake can lead to constipation.
True
Balance in fiber intake is important for digestive health.
What is the key characteristic of sarcopenia according to the European Working Group on Sarcopenia?
Low muscle strength
The European Working Group on Sarcopenia (EGWSOP 2) emphasizes this characteristic.
What are frequently present in sarcopenia besides low muscle strength?
- Increased inflammation
- Significant weight loss
- Decline in physical function
These factors often accompany the condition but are not defining features.
What defines sarcopenia?
Low muscle quality and/or quantity
These are considered the defining features of sarcopenia.
How is sarcopenia classified in terms of diseases?
It is formally recognized as a muscle disease
This classification highlights the seriousness of the condition.
What is the first step in treating hepatic encephalopathy?
Lowering blood ammonia concentrations with medications, such as lactulose and/or rifaximin.
What is the recommended protein intake for patients with cirrhosis?
1-1.5 g protein/kg/d to prevent muscle catabolism and promote gluconeogenesis.
Should protein be restricted in cirrhotic patients with hepatic encephalopathy?
No, protein should not be restricted as it may increase protein breakdown.
In what situation might protein intake be withheld in cirrhotic patients?
In critically ill patients with severe acute liver failure, at risk for cerebral edema.
How long may protein intake be withheld in critically ill patients with severe acute liver failure?
For 24-48 hours until liver function improves.
What may be initiated in patients with persistent hepatic encephalopathy despite treatment?
A branched chain amino acid (BCAA) enriched enteral formula.
