Module 6 - Considerations in Nutrition Support of the Older Adult (V.5)

Question 1

Which of the following is most likely to be observed first for a patient with no history of diabetes who is overfed?
A. Hepatobiliary effects
B. Hyperglycemia
C. Weight gain
D. Accumulation of carbon dioxide

Answer 1

B. 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 2

Which of the following is NOT a component of the Comprehensive Geriatric Assessment (CGA) tool?
A. Exercise level
B. Anthropometry
C. Quality of life
D. Biochemical markers

Answer 2

A. Exercise level

The domains of CGA include physical, medical condition including nutrition status, mental health conditions, functional status, social circumstances, and environment. 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 3

An older adult receiving PN therapy may be more susceptible to metabolic complications related to
A. macronutrient deficiencies.
B. impaired cardiac function.
C. impaired thyroid function.
D. impaired autoimmune function.

Answer 3

B. impaired cardiac function.

Older adults have increased metabolic complications associated with PN therapy due to insulin resistance, impaired cardiac and renal functions and micronutrient deficiencies. Repletion of lean body mass (LBM) is slower.

Question 4

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?
A. 0.6 grams/kg
B. 0.8 grams/kg
C. 1.5 grams/kg
D. 2.5 grams/kg

Answer 4

C. 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 5

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?
A. Decrease in protein provision to 0.6 g/kg/d
B. Formula high in medium chain triglyceride content
C. Formula enriched with branched-chain amino acids
D. Lactulose and rifaximin therapy

Answer 5

D. 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 6

Which of the following best reflects the use of artificial nutrition and hydration (ANH) in patients with a Do Not Resuscitate (DNR) status?
A. The DNR status is a contraindication to the provision of ANH
B. The DNR status should not preclude the initiation of ANH if the indications exist
C. The provision of ANH to a patient with a DNR status is based on individual state laws
D. ANH cannot be withheld or withdrawn in a patient with a DNR order, even if all agree that ANH is no longer meeting the desired goal

Answer 6

B. 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 artificial nutrition and hydration (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 is NOT a common change in the body composition of healthy older adults?
A. Increased body water
B. Decreased bone mineral mass
C. Decreased lean body mass
D. Redistributed fatty tissue

Answer 7

A. 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 8

An older adult receiving digoxin and parenteral nutrition who is experiencing signs of digoxin toxicity should be assessed for
A. hypokalemia.
B. hypocalcemia.
C. hypermagnesemia.
D. hypophosphatemia.

Answer 8

A. hypokalemia.

Digoxin is prescribed for arrhythmias and CHD and often paired with diuretics. It is a water soluble drug which is eliminated solely via renal excretion. The elderly are at an increased risk of digoxin toxicity due to many factors such as: renal insufficiency, hypokalemia, hypomagnesemia, hypercalcemia and advanced age. Digoxin toxicity may occur despite therapeutic concentrations because depletion of potassium or magnesium will sensitize myocardia to digoxin and also causes arrhythmias.

Question 9

An 80 year old nursing home resident with a history of constipation has a newly placed percutaneous endoscopic gastrostomy (PEG) tube. Which enteral formula would be an appropriate choice to provide?
A. Concentrated 2 kcal/mL formula
B. Standard 1 kcal/mL formula
C. Semi-elemental 1.5 kcal/mL formula
D. Elemental 1.5 kcal/mL formula

Answer 9

B. 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, 2 kcal/mL concentrated formula contains less free water and usually less fiber, and may exacerbate the constipation. Semi-elemental and elemental formulas are not indicated for constipation.

Question 10

Which one of the following vitamin deficiencies is most likely to occur in a person who consumes alcohol on a regular basis?
A. Vitamin K
B. Vitamin C
C. Vitamin D
D. Vitamin B1

Answer 10

D. Vitamin B1

Long-term alcohol abuse may lead to Wernicke encephalopahty and Wernicke-Korsakoff syndrome, which are associated with thiamin (vitamin B1) deficiency. Regular alcohol intake can affect absorption and/or utilization of vitamins B6, B12, B9 (folic acid), and C. Additionally, fat soluble vitamins can also be impacted as alcohol inhibits fat absorption and thereby impairs absorption vitamins A, E, and D. Iron and zinc absorption may also be affected by excessive alcohol intake. However, frank deficiency would be more common with thiamin.

Question 11

Which of the following is most likely to occur as the result of an age-related functional change in the gastrointestinal (GI) tract?
A. Increased anorectal tone
B. Decreased vitamin A absorption
C. Increased calcium absorption
D. Decreased gastric emptying

Answer 11

D. Decreased gastric emptying

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 12

Sarcopenia, the loss of lean body mass that occurs with aging, is also associated with
A. excess growth hormone.
B. decreased cytokine activity.
C. decreased bone density.
D. decreased total body fat.

Answer 12

C. 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 13

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?
A. Hyperkalemia
B. Hypochloremia
C. Hypermagnesemia
D. Hypophosphatemia

Answer 13

D. 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 14

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:
A. consult with a lawyer regarding physician orders for life-sustaining treatment.
B. have a psychiatric evaluation in order to be declared competent to make decisions in the patient’s care.
C. honor the patient’s expressed wish to withdraw nutrition and hydration by medical means.
D. decide, based upon own values, whether or not to withdraw the patient’s nutrition and hydration by medical means.

Answer 14

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

Advance directives are documents that allow individuals to document their treatment preferences and identify a surrogate or proxy decision maker to act in the patient’s state when he or she loses the ability to make decisions. Use or nonuse of artificial nutrition and hydration is a component of some advance directives. 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. In the absence of an advanced directive, 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 15

Vitamin D (25, hydroxyvitamin D) deficiency is defined as a serum level of less than
A. 20 ng/mL.
B. 50 ng/mL.
C. 100 ng/mL.
D. 120 ng/mL.

Answer 15

A. 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 16

Which of the following best describes sarcopenia that contributes to a decrease in energy related requirements?
A. Decreased fat mass and increased lean body mass
B. Increased fat mass and decreased lean body mass
C. Increased fat mass and increased lean body mass
D. Decreased fat mass and decreased lean body mass

Answer 16

B. Increased fat mass and decreased lean body mass

On average, adult energy needs decline an estimated 5% 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 17

Vitamin D (25, hydroxyvitamin D) deficiency can manifest as
A. muscle weakness.
B. decreased production parathyroid hormone (PTH).
C. hypotension.
D. decreased normal serum lipid levels.

Answer 17

A. 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 may 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. In Vitamin D deficiency PTH production is increased.

Question 18

Which of the following complications of enteral nutrition (EN) is the most potentially dangerous in the older adult?
A. Diarrhea
B. Abdominal distension
C. Leaking around the enterostomy tube insertion site
D. Aspiration

Answer 18

D. Aspiration

Sarcopenia and frailty seen in older adult populations are linked to dysphagia which can lead to aspiration of oral secretions. Pulmonary aspiration may result from reflux or muscle weakness and is one of the most serious complications of EN. It can result in 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 19

Enteral nutrition formulas supplemented with fiber are often used in the older adult population to prevent constipation. Which of the following considerations is most important if this type of formula is chosen?
A. Addition of a prokinetic agent
B. Avoidance of lactose
C. Decreased feeding rate to prevent bloating
D. Provision of adequate water

Answer 19

D. Provision of adequate water

Constipation is a common problem in the elderly. Common causes of constipation include dehydration and either inadequate or excessive fiber intake. Fiber helps propel waste through the colon, and inadequate fiber intake can result in infrequent bowel movements with significant waste buildup in the colon. For patients requiring long-term enteral feedings, a formula that contains fiber is often helpful to prevent constipation. If fiber is included in the enteral nutrition regimen, administration of 1 mL of fluid per kcal enterally may help prevent solidification of waste in the colon and constipation. Patients often need additional fluid to facilitate regular stool output and minimize the change of impaction.

Question 20

Elderly patient admissions due to adverse drug reactions can be decreased by recognizing this population has
A. increased hepatic blood flow.
B. increased sensitivity to warfarin and opiates.
C. increased glomerular filtration rate (GFR).
D. increased first pass metabolism.

Answer 20

B. increased sensitivity to warfarin and opiates.

There is a 35% reduction in hepatic blood flow in the elderly accompanied by reduced hepatic volume (28% in men and 44% in women by the age of 91). As a result, drug metabolism, particularly first-pass metabolism, may be considerably reduced. Pharmacodynamic (drug actions and side effects) changes also occur with reported changes with aging including increased response (i.e. sensitivity) to warfarin and opiates. Glomerular function (GFR) is reduced by 6-10% per decade after the age of 40, indicating by the age of 90 there may be a 30-40% reduction in overall renal function.

Question 21

An assessment of functional status may aid in determining nutrition risk. Which of the following provides an assessment of functional status?
A. Intelligence quotient exam
B. Handgrip strength assessment
C. Measurement of fat mass
D. Visual exam

Answer 21

B. 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 best describes the use of artificial nutrition and hydration (ANH) in terminally ill patients?
A. Those who receive ANH have a more comfortable death
B. Those who have dysphagia survive longer with ANH
C. Those who receive ANH have fewer electrolyte abnormalities
D. Those who forego ANH experience fewer side effects

Answer 22

D. Those who forego ANH experience fewer side effects

A common fallacy in terminally ill patients is that dehydration is thought to be an uncomfortable state. In fact, at the end of life, patients often experience a decrease in hunger and thirst drive. The analgesic theory proposes that starvation boosts the production of ketones, thereby having an anesthetic effect. Aggressive artificial nutrition and hydration (ANH) can be more harmful and can produce life-threatening symptoms including edema, ascites, nausea, vomiting, and pulmonary congestion. Numerous studies report that patients who are dying have electrolyte values that run in the normal range.

Question 23

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?
A. 10-20%
B. 30-40%
C. 50-60%
D. 70-80%

Answer 23

B. 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 24

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?
A. Decreased taste sensation
B. Social isolation
C. A liberalized diet
D. Polypharmacy

Answer 24

C. A liberalized diet

Decreased oral intake by older adults can be related to multiple causes. Older adults often have multiple chronic medical conditions that require dietary restrictions 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. Diet liberalization has been shown to make meals more palatable and acceptable to older adults.

Question 25

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?
A. Zinc
B. Copper
C. Vitamin E
D. Chromium

Answer 25

A. 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 26

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
A. justice.
B. autonomy.
C. beneficence.
D. nonmalfeasance.

Answer 26

B. 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 defined as an ethical principle 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 27

Pharmacologic agents such as histamine2-receptor antagonists (H2 blockers) and proton-pump inhibitors (PPIs) are commonly prescribed for a variety of upper GI disorders such as prevention and treatment of gastric ulceration. Prolonged use of these medications may most commonly contribute to deficiency of which of the following micronutrients?
A. Vitamin C
B. Potassium
C. Vitamin B6
D. Vitamin B12

Answer 27

D. Vitamin B12

Risk of developing vitamin B12 deficiency increases 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. 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 cognizant of vitamin B12 status, especially in older adults receiving acid lowering medications.The other listed micronutrients are less likely to be affected by decreased gastric acid.

Question 28

Which of the following medication classes used in the older adult population will LEAST likely contribute to anorexia?
A. SSRIs
B. Anticoagulants
C. Antiarrhythmics
D. NSAIDS

Answer 28

B. Anticoagulants

The most frequent prescribed medications that may hinder appetite compromise include: Cardiovascular meds, Psychiatric meds and anti-rheumatic meds. Drug induced anorexia in the older population is also caused by polypharmacy due to increased risk of drug-drug interactions and GI problems.

Question 29

What is the most widely used tool to measure generic health-related quality of life?
A. Katz ADL
B. Lawton-Brody IADL
C. FIM
D. SF-36

Answer 29

D. 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 30

Which of the following medications is most likely to cause constipation in a patient receiving enteral nutrition (EN)?
A. Clindamycin
B. Kayexalate
C. Codeine
D. Magnesium oxide

Answer 30

C. 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 31

Which of the following tools includes the assessment of a long-term care resident’s ability to maintain adequate nutrition and hydration and is mandated by the Center for Medicare and Medicaid (CMS) for certified long-term care facilities?
A. Minimum Data Set (MDS)
B. Resident Assessment Protocols (RAP)
C. UtilizationGuidelines
D. Trigger Legend

Answer 31

A. Minimum Data Set (MDS)

The Center for Medicare and Medicaid (CMS) mandates that certified long-term care facilities use the Resident Assessment Instrument (RAI) as one screening and assessment tool. The RAI provides an interdisciplinary framework for resident assessments and the identification of problems. Problems identified are then required to have individualized care plans. The RAI consists of the Minimum Data Set (MDS) and the Care Area Assessment (CAA). The MDS is completed by the members of the interprofessional team who use it to assess all aspects of clinical status and facilitate problem identification (“triggers”). The CAA is then the investigation of “trigger” areas from the MDS to determine if further planning and intervention is required. The nutrition component of this assessment is found in section K of the MDS. This will assess the resident’s ability to maintain adequate nutrition and hydration and covers swallowing disorders, height and weight, weight changes, and nutrition approaches. Nutrition approaches include the use of mechanically altered and therapeutic diets and artificial nutrition and hydration (Nutrition support, including PN and EN), specifically documenting the mode and percentage of required intake by the artificial route.

Question 32

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

Answer 32

A. 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 33

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 warfarin therapy?
A. Vitamin K
B. Vitamin E
C. Vitamin C
D. Vitamin B1

Answer 33

A. Vitamin K

Two parenteral multivitamin products are currently available for adults, one with vitamin K and one without, but both meeting the FDA mandates. Vitamin K is also found in lipid emulsions, however the amount may vary from 0 to 290 mcg/L. Vitamin K can impact the effects of anticoagulation therapy, therefore, the INR should be monitored closely in these patients who are also receiving PN. Warfarin therapy should not be a contraindication to provision of a multi-vtiamin product with vitamin K.

Question 34

The Short-Form Mini-Nutritional Assessment (MNA-SF) was derived from the Mini-Nutritional Assessment (MNA) in order to
A. adapt the MNA for use in patients in the hospital setting.
B. eliminate the need to obtain height and weight data for nutrition assessment.
C. allow patients to generate their own nutrition assessment with a questionnaire method.
D. obtain high diagnostic accuracy for detecting nutritional problems in older adults with a brief screening tool.

Answer 34

D. 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 35

In an older adult who requires long-term home EN, which of the following complications is most often overlooked?
A. Tube leaking
B. Constipation
C. Decreased urine output
D. Skin problems at tube site

Answer 35

C. 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 36

An 85 year old woman is admitted to the hospital with a history of stroke, dysphagia, poor appetite and oral intake for one month and 10% weight loss. The patient is evaluated by the speech pathologist who recommends a pureed, honey thick liquid diet. Which nutrition intervention would be most appropriate for this patient?
A. Recommend calorie count
B. Initiate peripheral parenteral nutrition
C. Prescribe total parenteral nutrition
D. Initiate nocturnal enteral nutrition

Answer 36

D. Initiate nocturnal enteral nutrition

The most appropriate intervention would be to provide enteral feedings to supplement oral diet. Common indications for enteral nutrition include stroke and other neurologic disorders that impairs swallowing ability. Since there is no evidence of compromised gastrointestinal function, parenteral nutrition is not indicated.

Question 37

When using cyclic parenteral nutrition (PN) solutions for nonstressed patients, age may be an important factor in monitoring for complications because older adults have
A. higher rates of insulin resistance and hyperglycemia.
B. lower fat and oxidation.
C. higher fluid requirements.
D. lower concentrations of free fatty acids.

Answer 37

A. 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 38

In an afebrile adult with intact skin, insensible fluid loss from lungs and skin is approximately how many mL per day?
A. 500
B. 1000
C. 1500
D. 2000

Answer 38

B. 1000

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

Question 39

The Plan/Do/Study/Act (PDSA) cycle is employed as a
A. quality improvement problem-solving model.
B. method for determining root cause for a medication error.
C. tool for measuringhand grip strength in elderly patients.
D. compare PN utilization between institutions.

Answer 39

A. quality improvement problem-solving model.

The Plan/Do/Study/Act (PDSA) is one of the most common improvement strategies used in healthcare quality initiatives. 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 40

Which of the following is NOT appropriate to tell a family regarding nutrition at the end of life?
A. Dying patients rarely feel hungry or thirsty
B. Fewer calories are needed at the end of life
C. The experience of eating remains unchanged at the end of life
D. Patients should not be made to feel guilty if they do not wish to eat

Answer 40

C. 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 41

Which of the following medications is most likely to contribute to hyponatremia in an older adult?
A. Hydrochlorothiazide
B. Amlodipine
C. Warfarin
D. Simvastatin

Answer 41

A. 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. In comparison, loop diuretics (e.g. furosemide) can actually diminish ADH-induced free water absorption and treat hyponatremia in SIADH.The other agents listed do not commonly lower serum sodium.

Question 42

Which of the following is the hallmark of frailty seen with older adults?
A. Sarcopenia
B. Chronic inflammation
C. Dementia
D. Chronic disease

Answer 42

A. Sarcopenia

Frailty is described as a multifactorial syndrome that has various phenotypes and leads to significant changes in quality of life, vulnerability, and disability in older adults. Sarcopenia (loss of muscle mass and strength) is a hallmark of frailty. Other characteristics include unintentional weight loss (10 pounds in past 1 year), self-reported exhaustion, weakness (hand-grip strength), slow walking speed, and low physical activity. Inflammation of chronic disease, nutrition status, and oxidative stress also play a role in frailty.

Question 43

A decrease in food intake in older adults is most likely attributable to
A. decreased taste and flavor sensations.
B. age-related decreases in stomach capacity.
C. fear of stool or flatus incontinence.
D. enhanced olfaction sensation.

Answer 43

A. 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 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?
A. Peripheral parenteral nutrition (PN)
B. Central parenteral nutrition (PN)
C. Nasojejunostomy tube placement
D. Percutaneous endoscopic jejunostomy (PEJ) feeding

Answer 44

D. 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. The long-term small bowel access provided by a PEJ tube as opposed to a nasojejunostomy tube would be the best plan for this patient to prevent aspiration in the long-term. Parenteral nutrition is not indicated because the gut is functional.