Exam 1 Material

Question 1

Define aging.

Answer 1

The time-sequential deterioration that occurs in most living beings, including weakness, increased susceptibility to disease and adverse environmental conditions, loss of mobility and agility, and age-related physiological changes.

Question 2

Distinguish life expectancy from life span.

Answer 2

• Life expectancy: what proportion of the possible maximum age a person may live.
• Life span: a biological limit to how many years a species can expect to survive.

Question 3

Distinguish chronological aging from gerontological aging.

Answer 3

• Chronological aging: the number of years a person has lived.
• Gerontological age: calculated on the basis of the risk of dying, the so called force of mortality.

Question 4

Understand the 2 principal factors that determine functional performance in an older adult.

Answer 4

1: the rate of deterioration
2: the level of performance needed

Question 5

Be familiar with common changes with aging, and the clinical implications of those changes.

Answer 5

see table 1-1

Question 6

Name to what extent genetics (or heritability) affect life span versus environmental factors.

Answer 6

Heritability of life span accounts for =/< 35% of its variance, whereas environmental factors account for >65% of the variance.

Question 7

Explain aging from an evolution theory point of view.

Answer 7

This theory suggests that the design of current organisms resulted from an incrementally accumulative evolutionary process. From this POV, it is impossible for an organism to evolve in a way that reduces its life span, unless the evolution simultaneously improves the organism’s ability to produce adult descendents.

Question 8

Give a basic definition of damage theories on aging.

Answer 8

These theories suggest that aging is a result of wearing out caused by damage to fundamental life processes that occur in accumulative microscopic increments such as damage to chromosomes, accumulation of poisonous by product, nuclear radiation, or the forces of entropy.

Question 9

Describe the effect on life span caused by calorie restriction in animals.

Answer 9

• Caloric restriction lowers levels of oxidative stress and damage and extends the maximum life span of rodents.
• Caloric restriction, or nutritionally balanced semistarvation, when applied to mammals has been noted to increase life span as much as 50%.

Question 10

Discuss the theory of aging caused by telomere shortening.

Answer 10

With each cell division, a portion of the terminal end of chromosomes (the telomere) is not replicated and therefore shortens. It is proposed that telomere shortening is the clock that results in the shift to a senescent patten of gene expression and ultimately cell senescence.

Question 11

Name the functions of the mammalian target of rapamycin (mTOR).

Answer 11

1) senses cellular nutrient levels

2) and in turn, regulates rates of protein synthesis and energy utilization

Question 12

List 5 anticipated declines with aging.

Answer 12

1) cardiovascular function
2) strength
3) brain mass
4) bone mass
5) muscle mass

Question 13

Name 6 factors that have been shown to increase survival and functional independence in older adults.

Answer 13

1) normal renal function
2) good vision
3) avoiding afternoon naps
4) volunteer or compensated work
5) physical activity
6) instrumental activities of daily living (IADL)

Question 14

Describe diet and physical activity factors shown to have physical and mental health benefits in older adults.

Answer 14

• Diet: low in saturated fats and high in fruits and vegetables
• Physical activity: regular, at least 30 minutes daily

Question 15

Identify psychosocial changes that often cause physical or functional loss.

Answer 15

Transitions associated with aging are commonly noted around retirement, loss of a spouse or significant other, pet, home, car and ability to drive, as well as the loss of sensory function (hearing and vision), or ambulatory ability or capacity.

Question 16

Describe the older adult’s presentation of an illness and their reaction to stress or illness compared to a younger adult.

Answer 16

• reduced response to stress, including the stress of the disease
• symptom intensity may be dampened by the aged body’s decreased responsiveness
• “dampened primary sound in the presence of background noise”

Question 17

Identify examples of the 14 I’s common to geriatric patients.

Answer 17

1) immobility 8) isolation/depression
2) instability 9) inanition/malnutrition
3) incontinence 10) impecunity
4) intellectual impairment 11) iatrogenesis
5) infection 12) insomnia
6) impairment of vision and hearing 13) immune deficiency
7) irritable colon 14) impotence

Question 18

Know how to use the MNA and DETERMINE checklists.

Answer 18

see checklists

Question 19

Identify characteristics indicative of malnutrition for each tool.

Answer 19

• DETERMINE: (score of 3-5 moderate risk, 6+ high nutritional risk) disease, eating poorly, tooth loss/mouth pain, economic hardship, reduced social contact, multiple medicines, involuntary weight loss/gain, needs assistance in self care, elder years above 80
• MNA: (score of 0-7) food intake declined over past 3 months, weight loss during the last 3 months, mobility, suffered psychological stress or acute disease in the past 3 month, neuropsychological problems, BMI

Question 20

Take a calf circumference.

Answer 20

1. the subject should be sitting with the left leg hanging loosely or standing with their weight evenly distributed on both feet.
2. Ask the patient to roll up their trouser leg to uncover the calf.
3. Wrap the tape around the calf at the widest part and note the measurement.
4. Take additional measurements above and below the point to ensure that the first measurement was the largest.
5. An accurate measurement can only be obtained if the tape is at a right angle to the length of the calf.

Question 21

Take a demi-span measurement.

Answer 21

1. Locate and mark the midpoint of the sternal notch with the pen,
2. Ask the patient to place the left arm in a horizontal position.
3. Check that the patient’s arm is horizontal and in line with shoulders.
4. Using the tape measure, measure distance from mark on the midline at the sternal notch to the web between the middle and ring fingers.
5. Check that the arm is flat and wrist is straight.
6. Take reading in cm.

Question 22

Acknowledge that older adults usually present with multiple medical problems.

Answer 22

• Have different, often more complicated health care problems, such as multiple disorders, which may require the use of many drugs.
• On average, elderly patients have 6 diagnosable disorders

Question 23

Identify the amount of muscle mass that can be lost per day of bed rest.

Answer 23

5 to 6% of muscle mass and strength each day (causing sarcopenia)

Question 24

Name the common first sign of an underlying physical disorder in the older adult.

Answer 24

Mental or emotional

Question 25

Describe 7 factors that should be considered when obtaining a history from elderly patients and ways that clinicians can elicit more information from patients.

Answer 25

1) sensory deficits
2) underreporting of symptoms
3) unusual manifestations of a disorder
4) functional decline as the only manifestation
5) difficulty recalling
6) fear
7) age-related disorders and problems

• ask pts to describe a typical day
• ask whether pts have specific concerns

Question 26

Name 2 clues that the patient has experienced weight gain or weight loss.

Answer 26

1) fit of clothing

2) fit of dentures

Question 27

List nutrition-related items suggested to be included in the assessment of a geriatric patient.

Answer 27

Type, quantity, and frequency of food eaten are determined. Pts who eat =/< 2 meals a day are at risk of undernutrition.

1) any special diets or self-prescribed fad diets
2) intake of dietary fiber and prescribed or OTC vitamins
3) weight loss and change of fit in clothing
4) amount of money pts have to spend on food
5) accessibility of food stores and suitable kitchen facilities
6) variety and freshness of foods
- ability to eat, decreased taset or smell, decreased vision, arthritis, immobility, or tremors, urinary incontinence

Question 28

Be familiar with how a comprehensive geriatric assessment is conducted.

Answer 28

Comprehensice geriatric assessment is a multidimensional process designed to assess the functional ability, health (physical, cognitive, and mental), and socioenvironmental situation of elderly people.
-most successful when done by a geriatric interdisciplinary team, usually done in an outpatient setting, used mainly in high-risk elderly patients or if a referral has been requested

Question 29

Identify 6 ways in which comorbidities may affect nutrition status.

Answer 29

1) type of food consumed (restrictive diets)
2) the way food tastes
3) decreased appetite
4) dysphagia
5) functional limitations related to eating
6) preparing and purchasing food

Question 30

Name specific locations on the body that are used to valuate loss of subcutaneous fat, muscle loss, or fluid accumulation.

Answer 30

• subcutaneous: orbital, triceps over rib cage
• muscle loss: wasting of the temples, clavicles, shoulders, interosseous muscles, scapula, and calf
• fluid accumulation: extremities, vuvlvar/scrotal edema, ascites

Question 31

Explain how loss of taste and/or smell may affect food intake.

Answer 31

• taste: threshold increases, decreases ability to discriminate sweet, salty, sour, and bitter (use more to enhance food)
• smell: decreases with age, inability to detect spoiled food

Question 32

Describe the relationship between unintentional weight loss and functional decline.

Answer 32

-unintentional weight loss is associated with functional decline

Question 33

List 9 possible medication side effects that would affect food intake.

Answer 33

1) changes in taste
2) changes in smell
3) xerostomia
4) GI discomfort
5) slow gastric motility
6) early satiety
7) thirst
8) anorexia
9) weight loss or gain

Question 34

Describe the relationship between Alzheimer’s disease and weight loss.

Answer 34

• occurs more frequently in AD than in any other dementias
• classic sign of AD
• elevations in cytokines can contribute to weight loss associated with AD
• Neuropathological changes in the brain contribute to weight loss (change in feeding behavior and memory, disturbed appetite signaling, lower orexigenic factor concentrations, volitional swallowing disorders, and alterations in taste or smell)
• side effects of medications used in AD can affect appetite or ability to eat

Question 35

Differentiate between ADLs and IADLs.

Answer 35

• ADL: basic daily self-care tasks, including bathing, dressing, eating, toileting, hygeine, and transferring
• IADL: more complex tasks required to live independently in the community, including housework and laundry, finances, driving/transportation, shopping, meal preparation, ability to use a phone, and medication administration

Question 36

4 common measurements of physical performance.

Answer 36

1) timed-up and go (TUG) test for gait
2) 30-second chair stand for lower extremity strength
3) 4-staged balance test for balance
4) handgrip strength for upper extremity strength

Question 37

Explain the nutrition risks related to living alone, being widowed, being a caregiver and living with a limited income.

Answer 37

• living alone: lonliness, impacting desire to cook and eat an adequate number of meals per day, more likely to be malnourished, less protein intake, fruit, and vegetable and reported more nutrition problems
• being widowed: affect appetite and dietary intake, lack of motivation to prepare food, loneliness associated with cooking and eating alone, unintentional weight loss, men may not possess the skills to shop, prepare meals, and cook for food, which might affect quality and quantity consumed
• caregivers: negative impact on eating behaviors, leading to both under- and overnutrition
• poverty: affects food security and nutrition status, tend to purchase food that is cheaper, less nutritious, and less healthy or skip meals all together, financial strain is related to malnutrition risk and is correlated with decreased food intake and unintentional weight loss

Question 38

Define drug-nutrient interaction.

Answer 38

An interaction resulting from a physical, chemical, physiological, or pathophysiologic relationship between a drug and a nutrient, multiple nutrients, food in general, or nutrition status.

Question 39

Define bioavailability.

Answer 39

The extent to which an administered drug becomes biologically available in the systemic circulation

Question 40

Define clearance.

Answer 40

A pharmocokinetic expression to define the elimination of a substance (due to metabolism and/or excretion) from the body as a volume of a compartment per unit of time (mL/min or L/h)

Question 41

Define cytochrome P450.

Answer 41

an enzyme systemresponsible for metabolizing a wide range of substances; often abbreviated as CYP and followed by a description of the isoenzyme family, subfamily, and number (eg, CYP3A4)

Question 42

Define disposition.

Answer 42

the physiologic absorption, distribution, and elimination (ie metabolism and/or excretion)

Question 43

Define effect.

Answer 43

the physiologic action of a substance at a cellular or subcellular target

Question 44

Define enzyme.

Answer 44

complex proteins that catalyze chemical reactions, biotransforming the ligand into one or more metabolites which may be physiologically active; drug metabolizing reactions are classifies as Phase 1 (oxidation) or Phase 2 (conjugation)

Question 45

Define gene polymorphism.

Answer 45

the presence of alternate nucleotide sequences for a gene in a population subset, thereby coding for an alternate expression of the protein

Question 46

Define malnutrition

Answer 46

general term for “poor nutrition status,” which refers to nutrient intake out of balance with requirements; it can refer to underweight, overweight, or obesity, and altered states of metabolism, as well as specific nutrient imbalances; best identified by a thorough nutrition assessment

Question 47

Define object

Answer 47

the influenced party or “victim” of an interaction

Question 48

Define pharmaceutic

Answer 48

the term relating to physical and chemical properties of drug molecules, as well as the design ans evaluation of drug delivery systems/dosage forms, and the monitoring of drug disposition following administration

Question 49

Define pharmacodynamics.

Answer 49

the term relating to the influence of the administered drug on the body, organ, or tissue

Question 50

Define pharmacokinetic

Answer 50

the term relating to the influence of the body on an administered drug

Question 51

Define precipitating factor

Answer 51

the initiating factor or “perpetrator” of an interaction

Question 52

Define physiochemical.

Answer 52

pertaining to the physical ad chemical properties of a substance (eg drug or nutrient

Question 53

Define receptor.

Answer 53

a protein that serves as a reactive site of attachment with some degree of affinity for a ligand (eg, drug or nutrient)

Question 54

Define transporter.

Answer 54

a membrane-embedded protein responsible for moving a substrate from one side of the membrane to the other; can be “active” requiring E as ATP or not; for example, organic anion transporting polypeptide and peptide transporters

Question 55

Define volume of distribution.

Answer 55

a pharmacokinetic expression to define the theoretical body volume that a drug distribute to after absorption; this is based on a substance’s unique distribution and binding throughout the body as determined by both physiological factors and substance-related factors and described as a volume per unit of body weight (L/kg)

Question 56

Describe when drug-nutrient interactions are clinically important and generally how these are managed.

Answer 56

• An interaction is considered to be clinically important if the precipitating factor produces significant change to the object of the interaction based on some measurable physiologic criteria.
• Close monitoring with modification to the regimens are often all that is necessary

Question 57

Categorize drug-nutrient interactions by the precipitating factor and the object of the interaction.

Answer 57

Precipitating factor/Object of the interaction

1) Nutrition status/Drug
2) Food or food component/Drug
3) Specific nutrient or other dietary supplement ingredient/Drug
4) Drug/Nutrition status
5) Drug/Nutrition status

see figure 2 “Drug-Nutrient Interactions”

Question 58

List 4 potential sites of interaction for drug-nutrient interactions.

Answer 58

1) in drug (or nutrient) delivery device or gastrointestinal lumen
2) gastrointestinal mucosa
3) systemic circulation or tissues
4) organs of excretion
see figure 3 “Drug-Nutrient Interactions”

Question 59

Compare current recognition of drug-drug interactions to drug-nutrient interactions.

Answer 59

• the science of describing drug-drug interactions has evolved considerably, to the point where they are widely recognized, identified, and managed in practice
• the recognition of DNIs’ importance to practice has grown much slower. The FDA does not include an evaluation of DNIs in its guidance process for drug development

Question 60

Name the 2 parameters of medications most likely to be influenced by malnutrition.

Answer 60

Drug distribution and drug clearance

Question 61

Describe 3 current methods of dosing weight-based medications in obese patients and their current shortfalls.

Answer 61

1) “ideal” body weight/empiric
2) “adjusted” body weight /correction factor used is rarely drug-specific
3) lean body weight/generalizes across all drugs based simply on the presence of obesity

Question 62

Explain one method of predicting whether food will enhance or inhibit the absorption of a drug

Answer 62

Data generated in vitro can often predict drug disposition and food effects using the Biopharmaceutics Classification System. There are four classes based on drug solubility and intestinal permeability.

Question 63

Identify 6 potential disturbances in gastrointestinal function caused by drugs that may lead to reduced food intake or absorption

Answer 63

1) taste disorder
2) xerostomia
3) stomatitis
4) nausea
5) vomiting
6) diarrhea

Question 64

Identify at least 3 methods by which a clinician or an institution may better recognize and prevent drug-nutrient interactions.

Answer 64

• recognize DNIs as part of the patient assessment process or the drug regimen review
• always be prepared to ask: is the pt’s presentation related to an interaction?
• broaden your understanding of the potential mechanisms of interaction
• review all medication orders for “existing or potential interactions between the medication ordered and food and medications the pt is currently taking”
• have a coordinated interdisciplinary team
• have a subcommittee to develop and maintain policies and procedures on DNIs

Question 65

Give appropriate advice for a patient who takes medication and wants to consume grapefruit juice.

Answer 65

• contains a compound that increases the absorption of some drugs, this can enhance their effect
• best not to take medications with grapefruit juice, drink it at least 2 hours away from when they take their medication
• if they often drink it, have them talk with pharmacist or doctor before changing their routine

Question 66

Identify general drug-nutrient interactions with analgesics, antacids, antibiotics, anticoagulants, anticonvulsants, antihistamines, anti-inflammatories, antihypertensives, antineoplastic agents, diuretics, laxatives, antihyperlipidemics, and psychotherapeutic drugs

Answer 66

• analgesic: cause stomach irritation, take with food
• antacid: regular use can lower absorption of B12, supplements may be needed
• antibiotics: some decrease Vit K synthesis by bacteria in our intestines, tetracycline+calcium can decrease antibiotic absorption, some more effective on empty stomach but food can reduce chance of stomach irritation
• anticoagulants: be consistent in the amount of Vit K getting from foods, avoid eating large amounts of foods high in vitamin K (liver, broccoli, spinach, leafy greens)
• anticonvulsants: may cause diarrhea and decreased appetite, this can decrease availability of many nutrients, increase use of Vit D, Vit D may need to be supplemented, interact with folic acid, folic acid supplements affect blood levels of the drug
• antihistamine: increase appetite
• anti-inflam: long-term use can lead to stomach irritation and ulcers, take with food
• antihypertensives: affect body levels of minerals (K, Ca, zinc), if have diabetes can cause problems controlling blood sugar, natural licorice can increase blood pressure
• antineoplastic agents: irritate the cells lining the mouth, stomach, and intestines; many cause nausea, vomiting, and/or diarrhea; all of which can affect nutrient status
• diuretics: some increase urine losses of minerals (K, Mg, Ca); others limit mineral loss (esp K)
• laxatives: reduces time for nutrient absorption; excessive use can deplete vitamins and minerals; increase fluid loss/dehydration
• antihyperlipidemic: may decrease absortion of fat soluble vitamins, B12, folic acid, and calcium; longterm take a mutivit and Ca supplement
• psychotherapeutic: some decrease appetite; some increase appetite

Question 67

Identify 12 recognized core disciplines of complementary and alternative medicine.

Answer 67

acupuncture, homeopathy, hypnotherapy, manual therapies, healing, herbalism, chiropractic, creative and sensory therapies, reflexology, naturopathy and osteopathy

Question 68

Name the prevalence of CAM use in the United States.

Answer 68

estimated that CAM is used by approximately 1/3 of the population

Question 69

List 7 reasons that someone may use a CAM therapy.

Answer 69

1) improve quality of life
2) prevent illness
3) gaining a sense of control over a chronic illness
4) boasting the immune system
5) failures of orthodox medicine
6) dissatisfaction with conventional medical care
7) deal with the side effects of some conventional treatments

Question 70

Describe the relationship between number of chronic diseases and CAM use.

Answer 70

• use of CAM by older people varies by the number of chronic conditions experienced
• 9% of those with one chronic condition consulted a CAM provider, while 26% of those with 3 or more chronic conditions consulted a CAM provider

Question 71

Identify a patient who is most likely to use a CAM therapy.

Answer 71

-slightly more affluent, middle class, better educated, younger rather than the older retired (under 80, esp 70-80), and female

Question 72

Explain the lapse in communication about conventional and/or alternative treatment between patients and their healthcare practitioners.

Answer 72

-although patients may not tell physicians of their use, equally physicians may not record this information in patients’ charts

Question 73

Define and identify a dietary supplement.

Answer 73

1. a concentrate, metabolite, constituent or extract of a vitamin, mineral, herb, botanical, or amino acid
2. intended to supplement the diet
3. intended to be taken by mouth as a pill, powder, capsule, tablet, or liquid; and
4. labeled as a “dietary supplement”

Question 74

Describe the Food and Drug Administration’s oversight of dietary supplements.

Answer 74

• Any dietary supplement ingredients sold in the US prior to 1994 are presumed to be safe based on their historical use and are not regulated by the FDA
• After 1994 required to notify FDA and provide information on how the product works and how they can determine its safety and efficacy, then FDA decides whether to allow the product to come to market. results of scientific studies and trials are not required
• FDA can only remove the product from the market if it can prove that the product is not safe

Question 75

List the commonly reported uses, proposed mechanism of action, and clinical (interactions, side effects, and cautions) for the top 10 most commonly used dietary supplements (fish oil/omega-3, glucosamine/chondroitin, Echinacea, flaxseed/fiber, ginseng, gingko biloba, garlic, coenzyme Q-10, green tea, and cranberry.

Answer 75

See table 1, p 770-772 in Understanding the Properties of Common Dietary Supplements

Question 76

List 6 open-ended questions for healthcare professionals to ask patients about dietary supplement use.

Answer 76

1) WHAT are you currently taking? (dietary supplement, brand, dose)
2) WHY did you start taking it?
3) WHEN did you start taking it?
4) WHEN in the day do you take it?
5) WHO recommended the product or WHERE did you learn about the product?
6) HOW is it working?

Question 77

Name 4 roles for healthcare professionals regarding dietary supplement use.

Answer 77

1) communication
2) education
3) evaluation
4) documentation

Question 78

Name the 2 key variable that affect oral function in older adults

Answer 78

1) the number and distribution of remaining natural teeth, or indeed whether someone has any remaining teeth
2) the quantity and quality of saliva present

Question 79

Define 3 causes of xerostomia

Answer 79

1) disease and conditions associated with age
2) post-radiotherapy
3) drug use

Question 80

Identify foods that someone with chewing difficulty is likely to avoid

Answer 80

• stringy foods like beef or steak
• crunchy foods like raw carrot
• dry solid food like crusty bread

Question 81

List nutrients shown to be inadequate in the diet of someone who is edentulous compared to someone with teeth

Answer 81

energy, protein, fat, non-starch polysaccharide, calcium, vitamin A, vitamin C, niacin, vitamin E

Question 82

Name at least 3 potential solutions for poor oral health

Answer 82

1) replace missing nutrients with some form of dietary supplement
2) try to improve oral health and allow greater foods choice
3) technology/use of osseointegrated dental implants
4) dietary support and advice given to patients converted to endentulism for the first time

Question 83

Identify signs of and effects on nutrition of tooth decay, periodontal disease, candidiasis, thrush, xerostomia, and angular cheilitis/cheilosis

Answer 83

• tooth decay: can lead to abscess and consequent tooth extraction, can compromise biting and chewing of food
• periodontal disease: s/s foul odor of the mouth, bleeding or swollen gums, and loose mobile teeth; can lead to decreased nutritional intake, swallowing problem, and dyspepsia
• candidiasis: fungal infection associated with immune suppression, radiation therapy to the head/neck, and long-term use of antibiotics, corticosteroids, and cytotoxic agents. Pts who have diabetes, who wear dentures, or who have chronic xerostomia are at increased risk
• thrush: version of candidiasis, characterized by curdy white plaque, when rubbed off, it leaves a red, bleeding surface
• xerostomia: clinical signs include shiny mucosa, rampant decay, epithelial atrophy, inflammatory fissuring, inflammation with consequent infection of salivary glands, or candidiasis. Symptoms include burning sensation, sore tongue and lips, ulceration, difficulty with denture retention, dryness, abnormalities of taste and smell, and stickiness of the tongue to the palate.
• angular cheilitis/cheiliosis: lesions occurring in the corner of the mouth associated with mixed organisms (staphylococci, streptococci, and Candida albicans) are characteristic. B vitamin deficiencies, poorly fitting dentures, and xerostomia can be indicated

Question 84

Correctly order the steps to conduct an oral exam

Answer 84

1. Put on gloves
2. Ask pt to open/close mouth, watching for discomfort
3. Ask pt to remove any dental devices
4. Observe lips and corners of mouth, pulling lips forward to observe surfaces
5. Use penlight to observe corners of mouth and insides of cheeks, condition of gums or idges (if no teeth): should be pink
6. Look at roof of the mouth and under the tongue
7. Observe condition of the teeth
8. Note saliva: if thick, thin, not present

Question 85

Describe the oral preparatory, oral propulsive, pharyngeal, and esophageal phases of swallowing

Answer 85

• oral preparatory: bolus is heald in the anterior part of the floor of the mouth or on the tongue surface against the hard palate surrounded by the upper teeth. Oral cavity is sealed posteriorly by the soft palate and tongue contact to prevent the bolus from leaking into the oropharynx before the swallow
• oral propulsive: the tongue tip rises, touching the alveolar ridge of the hard palate just behind the upper teeth, while the posterior tongue drops to open the back of the oral cavity. the tongue surface moves upward, expanding the area of tongue-palate contact from anterior to posterior, squeezing the bolus back along the palate and into the pharynx
• esophageal: -lower esophageal sphincter relaxes during a swallow and allows the bolus passage to the stomach, a peristalsis wave carries the bolus down to the stomach through the LES (an initial wave of relaxation that accommodates the bolus, followed by a wave of contraction that propels it)

Question 86

Explain how swallowing and breathing are coordinated

Answer 86

Breathing ceases briefly during swallowing, not only because of the physical closure of the airway by elevation of the soft palate and tilting of the epiglottis, but also of neural suppression of respiration in the brainstem.
- When drinking a liquid bolus, swallowing usually starts during the expiratory phase of breathing. The respiratory pause continues for 0.5 to 1.5 s during swallowing, and respiration usually resumes with expiration.

Question 87

Define dysphagia, and list 4 consequences of dysphagia

Answer 87

-Dysphagia (abnormal swallowing) may lead to dehydration, malnutrition, pneumonia, or airway obstruction

Question 88

Name 4 structural abnormalities that may cause dysphagia

Answer 88

1) cleft lip and palate
2) cervical osteophytes
3) webs
4) strictures

Question 89

Describe the effects on the swallowing process of reduced closing pressure of the lips, weakness of the tongue and soft palate, loss of teeth xerostomia, and chemoradiation therapy

Answer 89

• Reduced closing pressure of the lips may lead to drooling.
• Weak contraction of the tongue and soft palate can cause premature leakage of the bolus into the pharynx, especially with liquids. Tongue dysfunction produces impaired mastication and bolus formation, and bolus transport.
• Loss of teeth reduces masticatory performance. Chewing can be prolonged by missing teeth, and particle size of the triturated bolus becomes larger due to lower efficiency of mastication.
• Xerostomia hampers food processing, bolus formation and bolus transport during eating.
• Chemoradiation therapy for head-and-neck cancer often causes delayed swallow initiation, decreased pharyngeal transport, and ineffective laryngeal protection.

Question 90

Differentiate between laryngeal penetration and aspiration

Answer 90

• Laryngeal penetration is defined as passage of the material transported from the mouth or regurgitated from the esophagus enters into the larynx but above the vocal folds.
• Aspiration is defined as passage of material through the vocal folds

Question 91

Identify the incidence of silent aspiration

Answer 91

Silent aspiration, or aspiration in the absence of visible response, has been reported in 25-30% of patients referred for dysphagia evaluations

Question 92

Name the relationship between poor oral hygiene and the risk of aspiration pneumonia

Answer 92

Poor oral hygiene can increase the bacterial load in the aspirate, increasing the risk of bacterial pneumonia.

Question 93

Describe the prevalence of dysphagia in all older adults, after stroke, and with dementia

Answer 93

• estimates suggest that 15% of the elderly population is affected by dysphagia
• Dysphagia is highly prevalent following stroke with estimates ranging 30%–65%
• up to 45% of patients institutionalized with dementia have some degree of swallowing difficulty

Question 94

List 8 complications associated with dysphagia post-stroke

Answer 94

-Complications that have been associated with dysphagia post-stroke include pneumonia, malnutrition, dehydration, poorer long-term outcome, increased length of hospital stay, increased rehabilitation time and the need for long-term care assistance,- increased mortality,

Question 95

Name 2 reasons that someone with dementia is at higher risk of dysphagia

Answer 95

• Most commonly, patients with dementia demonstrate a slowing of the swallowing process
• patients with dementia often have difficulties self-feeding.

Question 96

Explain how dysphagia may cause frailty in elderly people

Answer 96

-Dysphagia can contribute to malnutrition, and malnutrition can further contribute to decreased functional capacity. Thus, dysphagia may trigger or promote the frailty process among elderly persons.

Question 97

Identify the healthcare professional who is central in management of dysphagia

Answer 97

speech-language pathologists (SLP) play a central role in the management of patients with dysphagia

Question 98

Describe the purpose of postural adjustments

Answer 98

Changes in posture may alter the speed and flow direction of a food or liquid bolus, often with the intent of protecting the airway to facilitate a safe swallow.

Question 99

Recognize features of the supraglottic swallow, super supraglottic swallow, effortful swallow, and Mendelsohn maneuver

Answer 99

see Table 3 p291, Dysphagia in the Elderly-Management and Nutritional Considerations

Question 100

Name 2 levels of thickened liquids and the primary concern with their overuse

Answer 100

• honey and nectar thick

- A primary concern with the overuse of thickened liquids is the risk of dehydration in elderly patients with dysphagia

Question 101

Categorize allowed foods into each of the 4 levels in the National Dysphagia Diet

Answer 101

see Table 4 p293, Dysphagia in the Elderly-Management and Nutritional Considerations

Question 102

Briefly describe the concept and reported success of swallow rehabilitation

Answer 102

• The focus of swallow rehabilitation is to improve physiology of the impaired swallow. As such, many swallow reha- bilitation approaches incorporate some form of exercise
• exercise-based swallowing interventions have been shown to improve functional swallowing, minimize or prevent dysphagia-related morbidities, and improve impaired swal- lowing physiology

Question 103

For each of the 3 eye conditions, define the abnormality, and briefly list nutrition considerations for that condition.

Answer 103

1) Age-related macular degeneration: macula (center of retina) degrades, composed of lutein and zeaxanthin, fuit/veg may slow AMDR
2) glaucoma: high pressure inside eye presses on optic nerve, incrased risk with HTN, DM, CVA
3) cataract: clouding of lens, development delayed by antioxidant intake

Question 104

List 5 key points for basic guiding techniques

Answer 104

1) If the patient is not familiar with the surroundings, ask politely if they would like to be guided; do not be offended if your offer is not accepted
2) Offer your arm for the person to grip just above the elbow (they may prefer to grip your shoulder)
3) When guiding someone with sight problems, walk slightly in front, making sure that the pace is not too fast or too slow
4) If steps or stairs are involved always state whether they go up or down and give warning of approaching ground level
5) Explain changes in ground surface, such as moving from a tiled floor to carpet
6) Never guide someone into a seat backwards: instead, describe the chair, place your hand on the back of the chair, and enable the person to orientate themselves into the seat independently

Question 105

Name tips to improve healthcare for patients with visual impairment

Answer 105

see Box 2 p4, Improving healthcare access for people with visual impairment and blindness

Question 106

Recall body composition changes with aging.

Answer 106

Muscle mass decreases, while fat mass, especially visceral

fat, increases

Question 107

Define sarcopenia and sarcopenic obesity.

Answer 107

-Sarcopenia:an age-related quantitative and
qualitative change in skeletal muscle in which muscle
strength and muscle mass are decreased

-Sarcopenic obesity:the combination of sarcopenia
and obesity

Question 108

Describe how obesity may be a risk factor for sarcopenia and sarcopenia may be a risk factor for obesity.

Answer 108

-obesity a risk factor for sarcopenia: obesity has a similar pathophysiological burden on skeletal muscle with aging, including inflammation, oxidative stress, and insulin resistance.

-sarcopenia a risk factor for obesity:sarcopenia
is a risk for insulin resistance, loss of muscle mass
might also decrease energy expenditure and can facilitate
weight gain.

Question 109

List methods of measuring muscle mass.

Answer 109

1) DXA
2) CT
3) MRI

Question 110

Identify 5 consequences of sarcopenia and/or sarcopenic obesity.

Answer 110

1) Functional Decline
2) Atherosclerosis
3) Arterial stiffness in sarcopenia
4) Mortality risk
5) Metabolic syndrome

Question 111

Define osteoporosis and osteomalacia. 


Answer 111

In osteoporosis, bone mass decreases, but the ratio of bone mineral to bone matrix is normal. Osteoporosis results from a combination of low peak bone mass, increased bone resorption, and impaired bone formation. Osteoporosis is much more common than osteomalacia in the US. The two disorders may coexist, and their clinical expression is similar; moreover, mild to moderate vitamin D deficiency can occur in osteoporosis.

In osteomalacia, the ratio of bone mineral to bone matrix is low. Osteomalacia is due to impaired mineralization, usually because of severe vitamin D deficiency or abnormal vitamin D metabolism. Osteomalacia should be suspected if the vitamin D level is consistently very low. To definitively differentiate between the two disorders, clinicians can do a tetracycline - labeled bone biopsy.

Question 112

Name 8 risk factors for developing osteoporosis. 


Answer 112

1. Immobilization or extended sedentary periods
2. Low body mass index
3. Certain ethnicities (whites and Asians)
4. Insufficient dietary intake of Ca, P, Mg
5. Endogenous acidosis
6. Tobacco and alcohol use
7. Family history of osteoporosis, particularly a parental history of hip fracture
8. Patients who have had one fragility fracture

Question 113

Identify the best method of diagnosing osteoporosis. 


Answer 113

Dual-energy x-ray absorptiometry (DXA)

Question 114

List 8 laboratory values that are usually measured with osteoporosis.

Answer 114

1. T-scores
2. Z-scores
3. Serum Ca, Mg, and P
4. 25-hydroxy vitamin D level
5. Liver function tests – alkaline phosphatase (hydrophosphatasia)
6. Intact PTH level (hyperparathyroidism)
7. Serum testosterone in men (hypogonadism)
8. 24-h urine for Ca and creatinine (hypercalciuria)

Question 115

Name the recommended intake of elemental calcium and vitamin D for men and women. 


Answer 115

1000 mg/day elemental Ca for both men and women, 1200-1500 mg for postmenopausal women and older men, as well as periods of increased requirements (pubertal growth, pregnancy, and lactation)

800-1000I IU/day vitamin D, higher doses for those with deficiency

Question 116

Evaluate a patient’s total calcium intake from food, multivitamins, and supplements.

Answer 116

COMING SOON

Question 117

Explain why vegetables are often not a good source of calcium.

Answer 117

Few vegetables provide absorbable calcium in high enough amounts, nor do patients typically eat these foods on a daily basis. Certain vegetables contain compounds (such as oxalic acid), which can reduce their fractional absorption.

Question 118

Compare and contrast calcium carbonate and calcium citrate. 


Answer 118

Calcium carbonate is approximately 40% calcium. However, calcium carbonate is less soluble than calcium citrate, and requires the presence of stomach acid (therefore, food) to be best absorbed. Calcium carbonate is typically inexpensive and comes in many chewable forms.

Calcium citrate is 23% calcium, but it is water-soluble and does not need to be taken with food. However, the tablets are larger, more expensive, and there are few chewable versions available.

Question 119

Provide dosing advice for a patient taking a calcium supplement. 


Answer 119

Patients should be advised to spread their calcium dosed preferably 3 times a day - stressing that foods count as a “dose.” No more than 500-600 mg of calcium at one time, because fractional absorption begins to decrease slightly after that amount.

Question 120

Discuss the relationship between calcium supplements and kidney stones. 


Answer 120

A study by the WHI reported a 17% increase in risk of kidney stones in women taking calcium supplements, but research is mixed. Calcium oxalate stones are decreased with dietary calcium intake form dairy products, so it is prudent to recommend that patients who like dairy foods get at least some of their calcium from these sources to minimize calcium supplement use.

Question 121

Give dosing recommendations for vitamin D and explain why supplementation is almost always necessary. 


Answer 121

A daily dose of 1000-2000 IU from OTC supplements is recommended. Few foods are high in vitamin D, and most older patients do not produce enough from UVB rays due to lower levels of 7-dehydrocholesterol.

Question 122

Explain why serum calcium is not an indicator of bone health. 


Answer 122

Serum levels of calcium do not reflect intake. Because calcium homeostasis is tightly regulated via calcitonin, 1,25-dihydroxyvitamin D, and parathyroid, serum calcium is often normal even under conditions of low calcium intake.

Question 123

Describe the effect of alcohol, sodas, and caffeine on bone health.

Answer 123

Moderate consumption of alcohol seems to have a modest benefit on bone health, compared with no or excessive consumption, regardless of the type of alcohol. However, silicon in beer may provide additional benefits, and wine may also have components independent of alcohol content that are beneficial.

Data do not support the restriction of carbonated beverages for purposes of bone health. Studies suggesting the phosphoric acid content of dark sodas may lower bone density are observational and inconclusive. It is unwarranted to recommend that patients eliminate soda from their diets.

Excessive caffeine may be associated with accelerated bone loss in elderly women. Moderate caffeine intake is okay, eliminating is unnecessary.

Question 124

Describe the importance of maintaining muscle mass in an older adult.

Answer 124

• greater strength/muscle mass means you are at a reduced risk for death
• as we age we need to practice strategies to retain muscle: physical activity and adequate high quality protein

Question 125

Name 2 main stimuli for maintenance of muscle mass.

Answer 125

1) protein

2) exercise

Question 126

Explain the shortcomings of the protein RDA in an older adult.

Answer 126

• older persons eat less and don’t do well when consuming the RDA
• aging is associated with reduced food intake, predisposing to energy-protein undernutrition
• N excretion, muscle area, and strength, decreased in older subjects fed an isocaloric diet containing the protein RDA
• older adults may need more protein than the RDA
• older adults are not consuming these intakes

Question 127

List recommendations for protein intake in healthy older adults, those with acute or chronic disease, and those with severe illness, injury, or marked malnutrition

Answer 127

-healthy older adults:
1.0-1.2 g/kg
-acute or chronic disease: 1.2-1.5 g/kg
-Severe, illness, injury, or marked malnutrition:
up to 2.0 g/kg

Question 128

Describe the regulation of muscle mass and how muscle mass changes with exercise and with feeding.

Answer 128

• plastic tissue changes in terms of mass from hour to hour depending on amount of food consumed or amount of loading consumed
• feeding: protein synth occurs at same amount of protein break down during fasted state (if consume same amount of protein at each meal)
• exercise: greater muscle protein synthesis when and smaller loss in fasted state=result in skeletal muscle growth

Question 129

Name recommendations for protein intake at meals: how much is needed, and at which meals should protein be consumed?

Answer 129

• even amount at every meal

- 0.39g/kg wide margin of error

Question 130

Compare soy protein to whey and casein in terms of ability to promote muscle protein synthesis, and describe the physiology behind the protein type that best supports synthesis.

Answer 130

• soy to casein: Slowly digested micellar type protein not acid soluble and forms clotted form of protein in the stomach, it exits from the stomach slowly, digeted more slowly, provides ee for essential tissues than whey. Soy promotes a greater increase in both rested and exercised muscle protein synthesis than casein
• soy to whey: Whey is digested fast and transient and provides source of aa used by peripheral tissues. Whey promotes a greater increase in both rested and exercised muscle protein synthesis than both soy and casein

Question 131

Describe the relationship between bed rest and anabolic resistance

Answer 131

-bed rest results in anabolic resistance (reduced responsiveness to meal feeding) due to increased insulin resistance and inflammatory response

Question 132

Explain the relationship between calcium intake, protein intake, and calcium excretion

Answer 132

• higher protein more Ca excreted in urine of individuals
• increase in Ca excretion is assoc with an increase in Ca uptake that is promote by protein
• as long as consume sufficient Ca (1000mg) and sufficient Vit D (600 IU), higher protein intakes are associated with an increase efficiency of absorption of Ca and increase uptake of Ca into bloodstream and that’s why you see more Ca in the urine
• protein in addition to Ca and Vit D important to improve bone health

Question 133

Discuss the effect of dietary protein on age-related decline in renal function

Answer 133

• lower protein diet slows progression to overt renal failure
• problem with low-protein diet is that then you’re sub-optimally stimulating muscle synthesis and as a result start losing muscle so interventions to retain muscle like resistance exercise and testosterone therapy in men are part of cutting edge tx
• feed highest quality of protein, whey
• protein does not cause age-related decline in renal function

Question 134

Describe the relationship between aging, depression, and malnutrition

Answer 134

Depression affects up to 16% of older adults and is a significant risk factor for malnutrition.

Question 135

Compare and contrast delirium vs. dementia

Answer 135

• Delirium: AKA acute confusional state, sudden, last days to weeks, caused by another condition, usually reversible, almost always worse at night, attention is greatly impaired, level of consciousness is variably impaired, orientation to time and place varies, use of language is slow, often incoherent and inappropriate, memory varies, need for medical attention is immediate
• Dementia: serious loss of memory or cognitive function, slow and gradual, usually permanent, caused by a chronic brain disorder, slowly progressive, often worse at night, attention and level of consciousness is unimpaired until dementia has become severe, orientation to time and place is impaired, it is sometimes difficult to find the right word, memory is lost, medical attention is required but less urgent

Question 136

Define dementia, and list the 5 causes of dementia.

Answer 136

• Dementia: serious loss of memory or cognitive function, slow and gradual, usually permanent
  1) Vascular
  2) Brain Trauma (TBI) or infection
  3) Substance abuse (ETOH +/- drug)
  4) Malnutrition
  5) Degeneration of neurons (Alzheimer’s, Parkinson’s)

Question 137

Recognize 2 screening tools used for cognitive assessment.

Answer 137

1) Mini Mental Status Examination: series of questions

2. Mini-Cog: remember list + draw clock face and time

Question 138

Describe the pathophysiology and nutritional risk factors for Alzheimer’s disease

Answer 138

-Caused by buildup of beta-amyloid plaques and neurofibrillary tangles in brain: Theory that these block communication among cells, cause cell death

• High risk: high-fat dairy, red meat, organ meats, and butter
• Low risk: Salad dressing, nuts, fish, poultry, vegetables, fruit, garlic, spices

Question 139

Relate 6 characteristics of Alzheimer’s disease to nutritional implications

Answer 139

1) Reduced attention span: cannot focus on meals, need frequent reminders to eat and minimal
distractions

2) Forgetfulness: forget to eat, drink; a few forget they have already eaten
3) Reduced sensation of hunger and thirst: loss of comprehension
4) Visual agnosia: unable to recognize food as edible (or nonedible)
5) Loss of motor skills: unable to use utensils
6) Loss of social inhibition: need to be observed when eating with others (stealing food

Question 140

Describe the pathophysiology and 3 marked characteristics of Parkinson’s disease

Answer 140

• Caused by progressive loss of dopamine in substantia nigra (basal ganglia)
• Characterized by resting tremor, muscle rigidity, and bradykinesia

Question 141

Explain why people with Parkinson’s disease lose weight over time

Answer 141

Lower dietary intake!

Question 142

List 3 goals of nutritional therapy in Parkinson’s disease

Answer 142

1) protect neurons
2) manage drug-nutrient interactions
3) manage nutrition related side-effects

Question 143

Identify the diet that seems to protect against cognitive loss and its major features

Answer 143

-Mediterranean Diet: lots of fresh fruits and vegetables; olive oil, and fish, poultry, eggs, cheese, and yogurt much less often; meats, sugar, sweets much less often (1/wk or a couple of times/mo)

Question 144

Describe the levodopa-protein interaction and how this should be managed

Answer 144

• if protein taken at same meal, protein and levodopa compete for transport across blood-brain barrier = less drug action
• but often causes nausea if taken on empty stomach - separate from protein meals, TF

Question 145

Name 3 foods/supplements that should be carefully monitored in people who have Parkinson’s disease

Answer 145

1) Kava: causes Parkinson’s like symptoms, interferes with drug therapy, hepatotoxic
2) Fava beans: contains natural levodopa, may interfere with drug treatment
3) Vitamin B: may convert levodopa before reaches brain, do not supplement; whole food okay

Question 146

List 3 common gastrointestinal problems related to Parkinson’s disease and how each is
treated

Answer 146

1) Dysphagia: tx same as any dysphagia, speech language pathologist

2) Gastroparesis: sauses early satiety, nausea/vomiting
- Small, frequent meals + high calorie liquids

3) Constipation: already VERY common in older adults
- Fiber/fluid; coffee and tea may have neuroprotective effects
- Physical activity

Question 147

Provide interventions for behavioral problems associated with dementia

Answer 147

see Lecture notes, Table 41-7 from Krause text

Question 148

List 11 vitamins and minerals of concern for older adults

Answer 148

Vit A, Vit B1/Thiamin, Vit B12/Cobalamin, Folic Acid, Vit C, Vit D, Vit E, Vit K, Iron, Zinc, and Calcium

Question 149

Identify the relationship between dementia/delirium symptoms and vitamin A, thiamin, vitamin B12, folic acid, vitamin D, vitamin E, and zinc.

Answer 149

-Vitamin A: has been clinically shown to slow the progression of dementia and inhibit the formation
of β-amyloid fibrils, which is a feature of Alzheimer
disease

-Thiamin: in wet beriberi, in addition to peripheral neuropathy, patients will exhibit confusion,
ataxia, edema, tachycardia, and even coma. Wernicke encephalopathy, another manifestation of thiamine deficiency most encountered in people who misuse alcohol, consists of gait disturbance, confusion, and paralysis of extraocular movements.

Vitamin B12: studies report significant associations with vitamin B12 deficiency and risk of dementia or global cognitive decline

• Folic Acid: there may be a potential benefit of folic acid supplementation in stroke prevention as a result of its association with lowering of homocysteine levels and its effect in cardiovascular disease
• Vitamin D: Lower serum vitamin D status is also associated with poorer cognitive function in the elderly
• Vitamin E: Higher intake of vitamin E at baseline was associated with a lower long-term risk of dementia in some studies but not in others. Also of note, elderly persons exhibited a slower rate of global cognitive decline if they belonged in the highest quartile of intake of vitamin C, vitamin E, and carotenes.
• Zinc: Low zinc levels have recently been associated with Alzheimer disease, possible due to alterations in homeostasis that occur with aging

Question 150

Stage I Pressure Ulcer: Non-blanchable erythema

Answer 150

Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category I may be difficult to detect in individuals with dark skin tones. May indicate “at risk” persons.

Question 151

Stage II Pressure Ulcer: Partial thickness

Answer 151

Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister.Presents as a shiny or dry shallow ulcer without slough or bruising*. This category should not be used to describe skin tears, tape burns, incontinence associated dermatitis, maceration or excoriation.
*Bruising indicates deep tissue injury.

Question 152

Stage III Pressure Ulcer: Full thickness skin loss

Answer 152

Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and Category/Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage III pressure ulcers. Bone/tendon is not visible or directly palpable.

Question 153

Stage IV Pressure Ulcer: Full thickness tissue loss

Answer 153

Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling. The depth of a Category/Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow. Category/Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis or osteitis likely to occur. Exposed bone/muscle is visible or directly palpable

Question 154

Unstageable/Unclassified Pressure Ulcer: Full thickness skin or tissue loss – depth unknown

Answer 154

Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as “the body’s natural (biological) cover” and should not be removed.