Geriatric Nutrition Presentation

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  • Geriatric Nutritionhttp://www.aecom.yu.edu/nutrition/presentation/Presentation.htmNutrition Theme CourseAcademic Year 2008CJ Segal-Isaacson EdD, RDAlice Fornari, EdD, RDJudy Wylie-Rosett, EdD, RD

  • Session ObjectivesTo help students find practical ways of integrating nutrition assessment and treatment into geriatric medicine.To learn more about nutrition therapy for unintentional weight loss, malnutrition, hypertension, stroke and dysphagia.To identify geriatric nutrition resources on the web.

  • AECOM Nutrition Website: http://www.aecom.yu.edu/nutrition/default.htm Particularly useful parts of the AECOM Nutrition website:Nutrition resources: http://www.aecom.yu.edu/nutrition/links.htmNutrition presentations:

    http://www.aecom.yu.edu/nutrition/presentation/Presentation.htmNutrition Handbook for Medical Professionals

    http://www.aecom.yu.edu/nutrition/NutritionHandbook.htm

  • Im just not Hungry Geriatric Nutrition Case #1 Lauren Cantor, MBA; Alice Fornari, EdD; CJ Segal-Isaacson, EdD; Darwin Deen, MD and Lisa Hark, PhD

    Chief Complaint:Mrs. Heraldo is a 78 year old Latina woman brought in by her niece to you, her new primary care provider. The niece is concerned that Mrs. H looks much thinner. Mrs. H seems unconcerned about her weight loss and just repeats she is old now and just not hungry. Mrs. H has no idea if she has lost weight. However, her chart documents that she is 54 tall and weighed 174 lbs (BMI 29.9 kg/m2) 3 months ago. Today she weighs 154 lbs (BMI 26.4 kg/m2).

  • Continuation of Chief Complaint:The niece explains that her aunt lives alone in a subsidized, senior housing facility. Mrs. Heraldo tells you that her two children, both grown, live in California and Arizona and she sees them about once a year. Her husband died 5 years ago. Her eyes tear a bit as she tells you this.

  • Discussion Question #1-4What is the percentage of body weight that Mrs. H has lost in the last three months?

    Given that Mrs. Hs BMI is still in the overweight range, is her weight loss currently a significant issue? Why or why not?

    What should our weight goals for Mrs. H be at this point?

    Is Mrs. Hs weight loss to be expected at her age? Why or why not?

  • Involuntary Weight Loss in the ElderlyTotal body weight tends to peak in the 50s, remains stable until 70 and then slowly declines after age 70-75.Loss of lean body mass (LBM) starts in the 20s typically with a 0.3 kg loss each year and which is usually offset by an increase in body fat that continues at least until 65-70 years of age. This can represent a loss of 40% of LBM!Weight loss per se is NOT a normal part of aging. In the very healthy elderly, weight loss is typically in the range of only 0.1 to 0.2 kg per year.

  • Two studies found that intentional weight loss also led to increased mortality due to loss of LBM, bone, and malnutrition from overly restrictive diets.EpidemiologyThe incidence of involuntary weight loss in community-dwelling elderly is between 5-15% of that population and more than 25% in frail elderly receiving home care services.One year documented weight loss of greater than 4-5% was the single best predictor of death within two years. (Wallace et al.).Newman AB, Yanez D, Harris T, Duxbury A, Enright PL, Fried LP. Weight change in old age and its association with mortality. J Am Geriatr Soc. Oct 2001;49(10):1309-1318.

    Wallace JI, Schwartz RS, LaCroix AZ, Uhlmann RF, Pearlman RA. Involuntary weight loss in older outpatients: incidence and clinical significance. J Am Geriatr Soc. Apr 1995;43(4):329-337.

  • Discussion Question #5How do the physical effects of weight loss from decreased energy intake (reduced calories) differ from cachexia? What are the physiological effects of both?

  • Body Composition ChangesSimple weight loss (From decreased caloric intake)70-80% body fat20-30% lean body massCachexia: (From chronic inflammation)70-80% lean body mass20-30% body fat

    Cachexia-related metabolic changes: Hepatic acute-phase protein synthesisIncreased skeletal muscle breakdownNegative nitrogen balanceIncreased lypolysisHyperinsulinemiaIncreased gluconeogenesis

    Wallace JI, Schwartz RS. Epidemiology of weight loss in humans with special reference to wasting in the elderly. International Journal of Cardiology. 2002/9 2002;85(1):15-21.

  • Discussion Question #6What are some of the causes of inadequate food intake in the elderly?

  • The Nine Ds of Inadequate Food Intake and Weight LossIn The Elderly:In about 25% of cases, there is no clear etiology for weight loss.When etiology is established the most frequent reasons are: DepressionGI (peptic ulcer or motility disorders)Cancer

    DiseaseDentitionDepressionDysgeusiaDrugsDysfunctionDementiaDiarrhea/MalaborptionDysphagia

  • Discsussion Questions #7-8What questions would you ask Ms.Heraldo to help narrow down the possible causes of her weight loss?

    What other tests would you consider performing?

  • Diagnostic Algorithm

    Wallace JI, Schwartz RS. Epidemiology of weight loss in humans with special reference to wasting in the elderly. International Journal of Cardiology. 2002/9 2002;85(1):15-21.

  • Discussion Question #9To recoup: How much weight loss is considered a clinically significant amount to lose over a 12 month period?

  • Past Medical and Surgical HistoryMrs. H has hypertension and hyperlipidemia, which were diagnosed 15 years ago. She has been on various hypertensive medications over the years. Her current regimen consists of Hydrochlorothiazide 25 mg daily, Atenolol 50 mg daily, Norvasc 5 mg daily, and Zocor 40 mg daily. Her family medical history includes hypertension and diabetes in both parents and an older sister who died from a stroke 5 years ago at the age of 76. Mrs. H denies any other significant past medical history.When asked about her weight history, she recalls that she was an average girl until after her first child at which point she gained about 15 lbs with each of her three children. She also says that she gained about 20 lbs when she stopped smoking 20 years ago.

  • Discussion Question #10Match the side effects associated with the medications Mrs. H is taking.Zocora. depressionNorvascb. hepatitisAtenololc. peripheral edema

  • 1 with b2 with c3 with a

  • Discussion Question #11Which of the following medications may cause loss of appetite in the elderly? NSAIDSPsuedoephedrineTheophyllineMegestrol AcetateAntineoplasticsAntihistamines

  • Appetite loss: Psuedoephedrine, Theophylline, Antineoplastics.

    Increased appetite: NSAIDS, Megace and Antihistamines.

  • Discussion Question #12Is there an appetite stimulant we should consider prescribing to Mrs. H? If so, what are they?

  • Appetite Stimulants:Megestrol Acetate (Hydroxyprogesterone)Promotes appetite and causes weight gain but most studies show increased weight is fat, not LBMSide effects may include fluid retention, nausea, glucose intolerance, venous thrombosis, reduced testosterone levelsMarinol/DronabinolRecent retrospective study1 shows that it was well-tolerated in the elderly and showed modest weight gains of 3 8.01lbs. Major side effect is dizziness. Frequently given at night before bed to mitigate dizziness.

    1.Wilson MM, Philpot C, Morley JE. Anorexia of aging in long term care: is dronabinol an effective appetite stimulant?--a pilot study. J Nutr Health Aging. Mar-Apr 2007;11(2):195-198.

  • Growth HormoneA 4 week trial showed slightly faster weight gain than no medication but no long-term sustained effect over food alone.1 Growth hormone in other settings have shown increased mortality. Also, growth hormone must be given by injection. Oxandrolone and NandroloneSeveral small trials in the elderly with androgenic analogs have not shown they lead to enhanced weight gain. Testosterone (In men with low levels) May be useful for elderly men with hypogonadism to build muscle back.

    1.Chu LW, Lam KS, Tam SC, et al. A randomized controlled trial of low-dose recombinant human growth hormone in the treatment of malnourished elderly medical patients. J Clin Endocrinol Metab. May 2001;86(5):1913-1920.

  • CyproheptadineThis is an antihistamine that increases appetite through its antiserotonergic effect on 5-HT2 receptors in the brain. However, a trial done in 1990 did not show that cyproheptadine was effective in promoting weight gain in cachexic cancer patients.

    Non-Pharmacological Appetite StimulantsAlcohol and Salty NibblesAlthough this is anecdotal information, a little wine or beer and a few salty mouthfuls such as olives eaten before a meal may enhance appetite.Encourage greatest food consumption when patient is most rested.

    1.Kardinal CG, Loprinzi CL, Schaid DJ, et al. A controlled trial of cyproheptadine in cancer patients with anorexia and/or cachexia. Cancer. Jun 15 1990;65(12):2657-2662.

  • Brief 24 Hour Food RecallMrs. H lives alone and reports that she shops and cooks for herself. She says that she eats two meals a day and that she eats pretty much the same thing every day. Her 24 food recall for yesterday is:Morning: 1 cup of instant coffee with non-dairy creamer, 1 tsp sugar and 1 slice toast with 1 tsp margarine and 1 tsp jam. Noon: 1/2 can chicken noodle soup, 3-4 saltines and 1 slice American cheese. Evening: 1 broiled chicken thigh, 1 spoonful of string beans and 1 spoonful rice. She drinks at least 5 cups of water a day and sometimes has a cup of tea with 1 teaspoon sugar and 2-3 vanilla wafer cookies before bed. She takes a daily multivitamin/mineral supplement.

  • Discussion Question #13Approximately how many calories is Mrs. H eating each day?

    Breakfast?Lunch?Dinner?Evening Snack?

  • Total: On a good d