Nutrition Flashcards
What is clinically important involuntary weight loss?
5% weight loss over a one year period
>10 pounds in six months
>5% in 30 days
10% in 180 days
What subsets of the elderly are most impacted by involuntary weight loss?
- Patients with dementia, especially those that are institutionalized (50% vs. 30% non)
- Frail elderly
What are some effects of involuntary weight loss in the elderly?
- Increased frailty and mortality
- Increased hospital admissions and increased risk of in-hospital complications
- Increased falls and injuries from falls
- Impaired cell-mediated and humoral response with increased rate of infections
- Loss of lean body mass with impaired skeletal muscle, cardiac muscle, and respiratory function
- Delayed wound healing
- Decreased functional ability and ADLs
- Higher rates of admission to an institution
- Poorer quality of life
What are some approaches to dealing with reversible weight loss?
- assessment
- diagnosis
- treatment
What are some problems associated with trying to treat irreversible weight loss? What are some examples of irreversible weight loss?
Trying to treat irreversible weight loss can be…
- frustrating
- painful
- emotionally draining
- expensive
- fruitless
- examples: dementia, cancer
What are some causes of weight loss in older adults?
- Physiological
- Medical
- Functional
- Psychological
- Social
What are some physiological factors that contribute to anorexia in aging, particularly thinking about chemosensory changes?
Diminished sensory-specific satiety
Change in taste and smell
- Increased threshold for salt other specific tastes
- Decreased taste sensitivity due to decreased taste receptor turnover (number of taste buds does not change)
- Medications that alter senses of taste and smell
What are some physiological factors that contribute to anorexia in aging, particularly thinking about GI factors?
Delayed gastric emptying
- Prolonged antral distention
- Increased absorption time
What are some physiological factors that contribute to anorexia in aging, particularly thinking about gut hormones?
- Elevated levels of glucagon (GLP-1), CCK, and leptin (increase satiety, decrease hunger, decrease food intake)
- Decreased levels of ghrelin (growth hormone produced by the stomach that increases appetite and food intake)
What are some medical clauses of involuntary weight loss?
- Malignancy
- Infectious (bacterial, TB, fungal, parasitic)
- Inflammation (autoimmune diseases like rheumatoid arthritis)
- Endocrine (DM, hypo/hyperthyroid, adrenal insufficiency)
- Organ failure (CHF, chronic renal insufficiency, COPD)
- Medication side effects
- Deficiencies (B12, folate, iron, thiamine, Vitamin C, zinc)
What are some medication side effects that can contribute to weight loss?
- Anorexia
- Dry mouth
- Dysgeusia/dysosmia
- Nausea/vomiting
What are some types of medications that can cause anorexia?
- Antibiotics
- Anticonvulsants
- Metformin
- SSRIs
What are some types of medications that can cause dry mouth?
- Anticholinergics
- Antihistamines
- Diuretics
- Clonidine
What are some types of medications that can cause dysgeusia/dysosmia?
- ACEIs
- Antibiotics
- Anticholinergics
- CCBs
What are some types of medications that can cause nausea/vomiting?
- Antibiotics
- Digoxin
- Hormone replacement
- Iron
- Potassium
- SSRIs
- Statins
What are some functional causes of involuntary weight loss?
- Immobility
- Arthritis
- Stroke
- Parkinson’s disease
- Dental problems
- Visual loss
- Hearing deficits
What are some psychiatric/psychological causes of involuntary weight loss?
- Depression
- Psychosis
- Grief/bereavement
- Intentional
- Alcoholism
- Dementia
- Anorexia nervosa/anorexia tardive
What are some social causes of involuntary weight loss?
- Poverty
- Isolation
- Neglect
- Abuse
- Caregiver fatigue
How do we evaluate a person’s weight loss?
- Weigh the patient
- Calculate BMI (undernutrition < 22)
- Careful H&P with emphasis in pharmacologic and psychosocial factors
- Lab studies
What are some basic screening tests that we should collect on a patient with suspected involuntary weight loss?
- UA
- CBC,
- Electrolytes
- LFTs
- TFTs
- Renal function
- Stool occult blood
- CXR
Consider upper and lower endoscopies
What are some diagnostic indicators of poor nutrition?
- Albumin < 3.4 g/dL
- Cholesterol < 160 mg/dL
- Transferrin < 180
- Hgb < 12 g/dL
- Triceps skin fold thickness
What is a validated screening tool you can use to assess for malnutrition in your patients?
Mini nutritional assessment- short form
What are some nonpharmacologic treatments for involuntary weight loss?
- Minimize dietary restrictions
- Optimize energy intake (high energy foods at the best meal of the day, smaller meals more often “eat with the clock, not your appetite,” favorite foods and snacks)
- Optimize and vary dietary texture
- Avoid gas producing foods
- Ensure adequate oral hygiene and health
- Take nutritionally dense supplements
- Eat in company or with assistance, hand-feed the patient
- Use lever enhancers, maximize taste and smell
- Participate in regular exercise
- Take a multiple vitamin supplements daily
- Use community nutritional support services, like Meals on Wheels
- Minimize aspiration risk by eating appropriate diet as evaluated by SLP
How does energy intake needs change with age?
- Energy intake needs declines significantly with aging due to reduction in basal energy expenditure and decline in physical activity
- Goal: 25 kcal/kg/day
What are the macros needed for older adults?
- Protein intake: 0.8-1.2 g/kg/day (higher in patients with pressure ulcers)
- Carb intake: minimum of 130 g/day, 50% complex, 20-30g fiber
- Fat intake: < 30% of total calories; < 10% saturated fat
How should older adults consume micronutrients so that they are receiving adequate amounts?
- Prefer dietary consumption of micronutrients over supplements
- May recommend a multi-vitamin on top of a nutritionally balanced diet
- May recommend other specific supplements based on lab work
What are some water soluble vitamins that are commonly deficient in the elderly?
Folate, RDA 400 ug/day
- No evidence of increased requirement in the elderly
- Low levels more common in elderly alcoholics (poor intake and decreased absorption)
- Over supplementation (> 1 mg) may mask vitamin B12 deficiency
Cyanocobalamine (B12), RDA 2.4 ug/day in adults > 51yo
- 10 to 15% elderly have the B12 deficiency from reasons like achlorhydria, antacid use, H. pylori infection, etc.
Thiamine (B1), mandatory enrichment of food ensures that the RDA is met
- Low levels most common in elderly alcoholics (from poor intake and decreased absorption)
What are some fat soluble vitamins that we should watch in the elderly? What is the risk of supplementation of some of these vitamins?
Vitamin A, RDA 700 RE in women and 900 in men
- Requirement does not increase with age
- Clearance is reduced
- Risk for hypervitaminosis: significant toxicity with chronic ingestion (SE: Headaches, leukopenia, hypercalcemia)
Vitamin D, RDA > 70, 600-800 IU
- Requirement increases with age due to reduced skin photosynthesis, reduced sun exposure, reduced absorption, reduced 1 hydroxylation of 25(OH)D
Vitamin E
- Deficiency is limited to cases of severe, long-standing fat malabsorption
- Amount in diet is usually adequate
What is the forgotten nutrient, and what are the needs of this nutrient in the elderly?
Water!
- Decreased thirst response
- Reduced concentration capacity by the kidneys
- Water needs: 1 mL/kcal or 30 mL/kg of body weight
What have studies concluded about protein and energy supplementation?
- supplementation appears to produce small but consistent weight gain
- statistically significant beneficial effect on mortality and a shorter length of hospital stay
What are some examples of oral supplements we can suggest to patients and what is each one’s use?
- boost plus: high cal, high protein
- carnation: very high cal, high protein
- resource diabetic: diabetic, high protein
- enlive: clear liquid supplement
- nubasics fruit beverage: clear liquid supplement
- gatorade: clear liquid supplement
- ensure pudding: consistency modified
- benefiber: fiber supplement
- procel: modular protein
- thicken-up: powder thickener
When should we consider consulting the nutritionist?
- enteral/parenteral support
- unintentional weight loss >5%
- n/v/d > 5 days
- poor oral intake, < 50% of meals > 3 days
- difficulties chewing, swallowing, aspiration precaution diet
- NPO > 3 days
- albumin < 3.4
- wound/pressure ulcer (any stage)
- transplant patients
- newly diagnosed of uncontrolled diabetic/CHF/ESRD
What are some pharmacological treatments for those with involuntary weight loss?
appetitie stimulants = orexigenig agents
- megestrol acetate
- dronabinol
- anabolic agents
- antidepressants
- gastroprokinetic agents
- other experimental drugs
what kind of med is megase and how does megestrol acetate help stop involuntary weight loss?
- progestational agent that produces an increase in food intake
- many studies show increase in weight gain, but some show only fat gain and not gain in lean body mass
- many studies show improvement in sense of well being =
what is the MOA of megase?
unclear
- alteration of CNS neurotransmitters involved in regulation of food intake
- antagonizes cytokine production (potent anorectic agents)
what is the typical dose and length of treatment needed for megase to be effective?
- doses range from 80-800 mg/day suspension
- studies show that the med needs to be provided longer than 12 weeks
what are common side effects of megestrol acetate?
- thromboembolism
- fluid retention
- flushing
- erectile dysfunction
- vaginal bleeding
- adrenal insufficiency
- diabetes
- decrease in testosterone levels
to which types of patients should we avoid giving megase?
bed-bound patients bc of increase in incidence of DVTs
what treatment is recommended for those on megase with urgent surgery or has an infection during treatment course longer than 8-12 weeks?
stress dose of steroids
how does dronabinol help those with involuntary weight loss?
- cannabis was used as an appetite stimulant in ancient Arabic medicine
- increases desire for food, improves taste, makes substances smell richer, decreases pain, and improves mood
- effective appetite stimulant for AIDS and cancer patient; antiemetic
what is the dosage for dronabinol?
2.5-20 mg/day (5-7.5 mg at HS for older demented patients)
what are the major side effects of dronabinol?
- delirium
- abdominal pain
- nausea
- ataxia
what are some anabolic agents used to prevent involuntary weight loss?
- testosterone
- anabolic steroids
- growth hormone and IGF-1
- glucocorticoids
how does testosterone help prevent involuntary weight loss?
increases muscle mass, decreases fat mass, and increases bone mineral density
what are the side effects of testosterone?
hct > 54%, leg edema, exacerbation of prostate cancer
what are the anabolic steroids used to prevent involuntary weight loss?
- oxandrolone and nandrolone
- improved weight
what are the side effects of anabolic steroids?
- liver toxicity
- fluid retention
- renal failure
what types of patients benefit from use of growth hormone and IGF-1? how do these prevent involuntary weight loss?
- severely ill, malnourished patients
- nitrogen retention and weight gain
what are the side effects of growth hormone and IGF-1?
- glucose intolerance/insulin resistance
- peripheral edema
- gynecomastia
what types of patients benefit from use of glucocorticoids? how do they prevent involuntary weight loss?
- hospice patients
- improve appetite and mood
limitations of glucocorticoids in regardings to helping involuntary weight loss?
have minimal impact of weight gain or function
what is the most common, treatable cause of anorexia and weight loss?
depression
what is the best antidepressant for helping with involuntary weight loss in older adults?
mirtazapine
what is the MOA of mirtazapine? how does it help with anorexia?
- enhances norandrenergic and serotoninergic neurotransmission
- this combo enhances appetite
- improved appetite and weight gain over SSRIs
what are some of the causes of eating problems in advanced dementia?
- oral dysphagia: absent or continuous chewing with tendency to pocket or spit food
- pharyngeal dysphagia: delayed swallowing initiation, multiple swallows, and aspiration
- loss of ability to perform task of eating
- loss of ability to interpret the sensation of hunger
- disinterest in food due to depression
- refusal to eat
what are the indications for placing a PEG tube according to the American Gastroenterological Association (AGA)?
- prolonged tube feeding (> 30 days)
- patient cannot/will not eat
- gut is functional
- patient can tolerate the placement of the device
what is the second leading indication for upper GI endoscopy?
PEG placement
what are some patient characteristics associated with a high likelihood of being tube fed?
- younger age
- nonwhite race
- lack of advanced directives
what does PEG stand for?
percutaneous endoscopic gastrostomy
what are some major complications of PEG placement?
- aspirations PNA
- peritonitis
- hemorrhage: puncture of gastric wall vessel
- buried bumper syndrome: migration of tube into the gastric wall and epithelialization of the ulcer site
- gastrocolocutaneous fistula
- wound infection
- necrotizing fasciitis
- inadvertent removal of PEB tube
what are some minor complications of PEG placement?
- tube leakage
- tube blockage
what are some of the goals that providers and caregivers are trying to achieve by placing a PEG in someone with dementia?
- provide nutrition and hydration
- reduce risk of aspiration PNA
- improve pressure ulcers
- improving nutrition parameters
- improve survival
- (facilitate transfer to LTC facilities)
- (increase caregiver convenience)
- (comply with LTC facilities’ policies)
what are some assumptions that people make about what a PEG tube will accomplish? are these things true?
- provide adequate nutrition
- prolong patient’s life
- eliminate suffering
- prevent aspiration PNA
- improve skin integrity by increasing protein intake (this is the only correct answer)
- improve functional status and/or quality of life
does a PEG prolong life?
- data doesn’t show survival advantage
does a PEG eliminate or cause suffering and why?
causes suffering 2/2
- surgical/wound issues: infection, bleeding, leakage, abscess, peritonitis
- increased use of restraints and subsequent pressure sores
- need for pharmacological sedation
- electrolyte disturbance
- aspiration PNA after placement
- increased urine and stool production, diarrhea or constipation, vomiting
- decreased contact with caregivers
- deprivation of the joy of eating
- increased number of transfers to acute care facilities due to tube dislodgement or leakage
do PEG tubes prevent aspiration PNA?
they are a risk factor of aspiration PNA and GERD
why do people still use PEG tubs in people with advanced dementia?
- economic incentives/NH issues
- path of less resistance
- state law
- family concerns over starving
- religious beliefs
- lack of understand of terminal nature of advanced dementia
- physician’s beliefs
what are some alternatives to PEG tubes?
- hand feeding
- easy-to-swallow high energy foods
- elimination of sedating medications
- improvement of dental hygiene
- swallowing cues
