Elderly Patients

Question 1

Which of the following best reflects the use of specialized nutrition support (SNS) in patients with a Do Not Resuscitate (DNR) status?

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4: SNS cannot be withheld or withdrawn in a patient with a DNR order, even if all agree that SNS is no longer meeting the desired goal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

2. The dNr status should not preclude the initiation of SNS if the indications exist

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 SNS can be withheld or withdrawn in patients with a DNR or DNAR if all concerned agree SNS is not meeting the agreed-upon goal.

References:

Barrocas A, Yarbrough G, Bencel PA, et al. Ethical and legal issues in nutrition support of the geriatric patients: The can, should and must of nutrition support. NCP. 2003;18:37-47.

Question 2

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

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

Answer 2

1. Obese elderly

Body composition is an important determinant of drug response. Distribution of fat soluble drugs is increased in the obese elderly 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.

References:

Pronsky ZM, Crow JP Food-drug interactions. In: Mahan LK, Escott-Stump, S, eds. Krause’s Food, Nutrition, and Diet Therapy, 11th Edition. Philadelphia: Saunders; 2004:455-474.

Question 3

When using cyclic parenteral nutrition solutions for nonstressed, nondiabetic patients, age should be taken into account because compared to the middle-aged, the elderly have

1: lower fat oxidation and lower glucose oxidation.
2: lower fat oxidation and higher glucose oxidation.
3: higher fat oxidation and lower glucose oxidation.
4: higher fat oxidation and higher glucose oxidation.

Answer 3

3. Higher fat oxidation and Lower Glucose Oxidation

Aging has been associated with alterations in substrate use metabolism. Substrate oxidation was compared between elderly and middle-aged patients during cyclic parenteral nutrition. Glucose oxidation decreases as age increases and can affect treatment tolerance during cyclic parenteral nutrition. The decreased glucose oxidation is possibly the result of higher insulin resistance in the elderly. Increased fat oxidation was correlated with increased age. Older patients had 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.

References:

Al-Jaouni R, Schneider S, Rampal P, et al. Effect of age on substrate oxidation during total parenteral nutrition. Nutrition. 2002;18 20-25.