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Landon Center on Aging
Landon Center on Aging  :  Geriatric Education & Training

Malnutrition in Older Adults

Instructor: Sharee A. Wiggins, NP, Post-MS(N), ARNP, BC-GNP, BC-ANP
Module Developed by: Sharee A. Wiggins, NP 2007; Revised 2010
Cases: developed with Daniel L. Swagerty, MD, MPH, CMD
Module edited by: Mary McDonald, MD (2007)

 

Specific Learning Objectives

A. Introduction:

Before reviewing the learning objectives and content, please take the Pre-Test.

Please review the Objectives, Content material, and Cases before our class session. We will apply the tasks in the Skills Objectives to these cases, and you should think about them ahead of time.

Upon completion of this Nutrition Module, medical students should be able to:

B. Attitudes

  • Recognize that poor nutritional status is an often overlooked reversible problem in the care of the aged.
  • Recognize that undernutrition is frequently a multifactorial problem of complex bio-psycho-social-cultural etiology.

C. Knowledge

  • Discuss aged-related physiologic changes and psychosocial risks that can predispose to poor nutritional health.
  • Relate potential complications associated with anorexia, involuntary weight loss (IWL), and protein energy malnutrition for older adults who are: community dwelling, hospitalized, and are residents in long-term care.
  • Briefly explain these conditions:  starvation, marasmus, cachexia, kwashiorkor.
  • Describe the diagnosis and management of protein energy malnutrition (PEM).

D. Skills 

  • List medications in which poor nutritional status is commonly an issue.
  • Complete a nutritional status assessment of an older adult in the office, home, and nursing facility. This will include the appropriate use of history, physical exam, and laboratory studies.
  • Recommend appropriate interventions for undernutrition in the office, home, and nursing facility settings.

E. Readings

Required Readings:

  • Thomas, D.R., Kamel, H., & Morley, J.E., (2004, February). Nutritional deficiencies in long-term care.  Parts 1, II, III.  Supplement:  Annals of Long-Term Care; 6(10): 325-332. Accessed July, 2009 online at:  http://www.annalsoflongtermcare.com/attachments/1079364363-NutritionLTC.pdf 

    Part I – Detection and Diagnosis.  John E. Morley, MB, BCh, David R. Thomas, MD, and Hosam Kamel, MD
    Part II – Management of Protein Energy Malnutrition and Dehydration.  David R. Thomas, MD,  Hosam K. Kamel, MD, and John E. Morley, MB, BCh
    Part III – OBRA Regulations and Administrative and Legal Issues. David R. Thomas, MD, Hosam K. Kamel, MD, and John E. Morley, MB, BCh

Additional Reading and Resources:
  • Swagerty, D., Zelenak, J., Dimant, J. (2002). Nutritional assessment and care of nursing facility residents: A practical approach. Journal of the American Medical Directors Association; 3(3):186-191   NOTE:  no online link.  Hardcopy available from faculty if student requests (D. Swagerty or S. Wiggins)
  • Wilson, M. G., & Morley, J. E. (2003). Physiology of aging. Invited Review: Aging and energy balance. Journal of Applied Physiology; 95:1728-1736. Available online with full free text pdf option at:  http://jap.physiology.org/cgi/content/full/95/4/17

F. Module Content: Nutrition, Undernutrition, Malnutrition

  1. Prevalence
  2. Types of Malnutrition
  3. Morbidity and Mortality Impact
  4. Normal Aging Changes
  5. Normal Requirements
  6. Contributing Factors
  7. Screening and Assessment

D. Cases

 

I.  PREVALANCE

Geriatric malnutrition is complex and multifactoral.  Additionally, three population subsets need to be considered when one speaks of “older adults”:  community dwelling, hospitalized, and institutionalized in long-term care settings.

Malnutrition as reduction in nutrient reserve

  • Ambulatory/Community Dwelling – 1% to 15%
  • Hospitalized – 35% to 65%
  • Institutionalized – 24% to 60
Protein-Energy Malnutrition (PEM):  presence of both clinical and biochemical changes consistent with undernutrition.
  • Ambulatory/Community Dwelling – 15%
  • Hospitalized – 20% to 65%
  • Institutionalized – 5% to 85%

II.  TYPES OF MALNUTRITION

  1. Kwashiorkor-like:  acute or subacute type of PEM that develops acutely or over weeks secondary to physiologic stress or low protein intake.  As depletion of visceral proteins (albumin, transferrin, prealbumin and retinol-binding protein) occurs, albumin levels drop, edema develops and there may not be any weight loss.  The mortality rate is high.  Older adults who already have low serum total cholesterol and serum albumin biochemical markers are at risk for more severe acute illness -- even with seemingly minor pathology due to accentuation of the normal age-related impaired immune response, hematologic function, and organ function.  Kwashiorkor may also develop concurrently with the pre-existing marasmus PEM subtype. [Learning aid: Kwashiorkor – Kwick]

  2. Marasmus: more insidious development over months to years due to poor food intake.  Muscle wasting (beyond age-related sarcopenia that can be found even in healthy, active older adults) develops in response to the metabolism of skeletal muscle.  Because muscle is metabolized rather than serum or visceral proteins, the serum levels are normal or close to normal.  Mortality is much lower than for kwashiorkor. However, marasmus can quickly develop into a kwashiorkor-like malnutrition during periods of acute illness.   [Learning aid: Marasmus – Muscles; Months]

  3. Cachexia:  hypermetabolic state of catabolism and proinflammatory responses (mediated by cytokines such as TNF, IL-1 and IL-6) that occur in both acute, life-threatening illnesses as well as chronic conditions that can elicit an acute-type response.  Examples include cancer, COPD, CHF and others.  Anorexia with reduced nutritional intake, fatigue, severe weight loss, increased insulin resistance, increased CRP, hypercortisolemia and reduced albumin synthesis can all occur.  Cachexia does not usually respond to hypercaloric intake.  Interventions are aimed at the underlying condition.

  4. Starvation: hypometabolic state that occurs due to lack of adequate food intake. Skeletal muscle mass is preserved until late in the starvation course.  Starvation does respond to hypercaloric intake.

  5. Undernutrition:  reduction in nutrient reserve

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III. MORBIDITY AND MORTALITY IMPACT

  • Inadequate dietary intake can contribute to, or exacerbate disease, advance age-related degenerative conditions, increase hospital stays and costs, delay illness recovery in outpatients, and increase mortality in older adults compared with older adults who are not nutritionally compromised.
    • Specific adverse effects of involuntary weight loss (IWL) in older adults:
      • Anemia, Immune dysfunction, Infections, Hip fracture, Pressure Ulcers, Fatigue, Decreased cognitive function, Edema, Muscle loss, Osteoporosis, Falls

  • NHANES III (National Nutrition Examination Surveys)
    • Older women (mean age 66) with 5% or more body weight loss over 10 years had two-fold increased risk of disability compared with women of stable weight
  • The Geriatric Anorexia Nutrition (GAIN) Registry
    • Adults living in LTC and losing weight have a higher mortality compared with those who stopped losing weight  [those who lost >5% weight in any one month had a 10-fold increase in risk for death compared with those who gained weight]
    • Those who gained weight had a lower mortality than those whose weight loss stabilized.

IV. NORMAL AGING CHANGES

  • Reduced bone mass, lean body mass and water content

  • Increased total body fat and intra-abdominal fat stores (nearly doubled adipose content after age 65)

  • Physiological Anorexia of Aging
    • Weight tends to stabilize until about the 6th or 7th decade, then slowly declines
    • Increased circulating cholecystokinin – satiating hormone
    • Reduced relaxation of the fundus allows for quicker passage of food into the antrum and this antral stretch also contributes to early satiety in older adults
    • Reduced BMR (basal metabolic rate) due to muscle mass losses
    • BMR is the primary determinant of total energy expenditure

  • Reductions in olfactory and gustatory (taste and texture discrimination) senses
    • Olfactory changes are thought to have a more negative impact on appetite than changes in taste buds
    • Mild decrease in saliva production

  • Decreased thirst perception, response to serum osmolality, and ability to concentrate urine following fluid deprivation
    • Generally, older adults not on fluid restrictions should take in about two quarts of total fluids daily
  • Constipation

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V. NORMAL REQUIREMENTS

  • Generally fluid requirements in older adults are roughly estimated to be at least 1500mls/day.  Other formulas are 30-35mls/kg; or, 1500mls the first 20kg + 20ml per additional kg.

  • A quick estimation of energy based on body weight:  25-30 kcal/kg/day

  • The Harris-Benedict (HB) equation is perhaps the most well-known and utilized formula for  decades for calculating energy needs in hospitalized adults.  It calculates Basal Energy Expenditure (BEE) and then incorporates gender and metabolic stress factors to estimate total energy demands. [Resting Energy Expenditure (REE) is slightly higher than BEE.]  Although the equation does not always correctly estimate energy needs, it may be the best available equation at this time.  A study published August 2007 in Clinical Nutrition, (26)4, 498-505 showed that of the 5 best known energy equations, the HB had the lowest mean difference between estimated needs and measured needs (using indirect calorimetry, a metabolic cart, to measure substrate utilization).  The HB equation and stress factors can be found at several websites.  Here is one of them: http://healthlinks.washington.edu/nutrition/section13.html

    • Macronutrient Needs
      • Pro – 0.8g/kg/day (1.5 g/kg/day if stress)**
      • Fat – 20% -35% total energy intake per day
      • CHO – 45% - 65% total energy intake per day
        • Specific conditions may dictate changes; for example:  COPD patients may have less CO2 retention by reducing CHO substrate metabolism and increasing fat calories.  The work of breathing (WOB) in COPD patients can lead to a pulmonary cachexia.
      • Fiber – 30 g/day (men); 21 g/day (women

**    Sarcopenia is the age-related development and progression of skeletal mass.  The mechanisms of the universal phenomenon are poorly understood.  However, research has suggested that moderate increases of dietary protein greater than 0.8g/kg/day may enhance anabolism and slow skeletal muscle mass losses with age.  This would not be appropriate in persons with renal disease.  Resistance training also slows sarcopenia and functional decline. Research abstract and full text from the American Journal  of Clinical Nutrition, May 2008, can be accessed online at:   http://www.ajcn.org/cgi/content/full/87/5/1562S

  • With osteoporosis in mind, most older women will need calcium supplementation to achieve a daily calcium intake of at least 1500 mg.
    • Ca+ critical to function of cells
    • 99% of calcium stored in bones /teeth
    • Serum calcium does NOT reflect bone calcium
    • Ca+ is leeched from bones if needed
    • 500 mg = Maximum absorbed at one time
      • Several forms of calcium
        • Dolomite, bone meal, unrefined oyster shell
          • Avoid due to potential lead & other toxic substances
        • Carbonate
          • Constipation and/or flatulence in some
          • Take with food for best absorption
          • Some very inexpensive forms
        • Citrate
          • Better tolerated
          • Most easily absorbed
          • May take with or without food

  • Vitamin D supplementation is also needed for calcium absorption particularly “sun-deprived” persons since Vitamin D synthesis in the skin requires the sun’s UV rays. Sufficient Vitamin D synthesis solely through the sun requires 5-30 minutes of unprotected sun exposure twice weekly. Complete could cover reduces UVB by 50%, shade by 60%, and there is no UVB penetration through glass.
    • Community dwelling older adults may be Vitamin D deficient due to sun reduction or avoidance due to skin cancer concerns and subsequent sun avoidance.
    • Institutionalized frail older adults are usually sun-deprived.

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VI.  CONTRIBUTING FACTORS TO UNDERNUTRITION

There are numerous risk factors for nutritional compromise, but it has been reported that the most important are:  low income, social isolation, high stress level, poor appetite, visual impairment, and medical illness. 

  1. Poverty and Near-poverty
    According to the Food Security Institute of Brandeis University, (February 2003) in 1997 the United States had the second highest poverty rate among older adults among the 19 industrialized countries. Older women, and older adults living alone or living with non relatives experience poverty rates higher than average.  Rural elderly have higher poverty rates than urban elderly; this gap is greatest in those aged 85 or older.  Since there is a close connection between insufficient income and hunger this suggests many older Americans are at risk for food insecurity and hunger. 
    • Food Insecurity:  “occurs whenever the availability of nutritionally adequate and safe food, or the ability to acquire foods in socially acceptable ways, is limited or uncertain.”

    • Hunger:  “uneasy or painful sensation caused by recurrent or involuntary lack of food and is a potential, although not necessary, consequence of food insecurity.  Over time, hunger may result in malnutrition."

    • Food Insufficiency:  “an inadequate amount of food intake due to lack of resources.”

    • Food Stamp Program:  available to all ages based on need and assets.  In FY2000, households with older adults represented 21% of all food stamp households.  In FY2001, of the food stamp households with elderly persons, 80% of these were older adults living alone.  Only 31% of eligible older adults received food stamp benefits in 2000.  Food stamp purchases are made using an Electronic Benefits Transfer card – similar to a bank card – rather than the old paper coupon system. 

    • In Kansas, The Supplemental Nutrition Assistance Program (formerly called food stamps) is administrated by the Kansas Department of Social and Rehabilitation Services. Special provisions apply for households with an elderly or disabled person or farm income.  Benefits are downloaded onto a unique debit card that can be swiped at the grocery checkout like any debit or credit card.

      Authorized by the Older Americans Act, The Administration on Aging’s Elderly Nutrition Program (ENP): provides funds for two senior nutrition programs administered by the Department of Health and Human Services Administration on Aging. The meals must provide a minimum of one-third of the recommended daily allowances (RDA).

    • The Older Americans Act (OAA) requires that nutritional programs provide nutritional screening.  The ENP program is available to anyone over age 60 plus, but it is not an entitlement program so there may be a waiting list or no service in some communities due to limited funding. Most Kansas communities have an Elderly Nutrition Program.

      • Congregate Meals:  hot meals offered to groups of older adults at a variety of locations such as senior centers, churches, schools and others.  Secondary benefits include reduction of isolation through the social setting.

      • Home Delivered Meals (aka:  Meals on Wheels):  meets the same criteria as congregate meals, but is provided for older adults unable to attend a congregate site.

  2. Functional Deficits:  visual impairments, immobility, tremors, dexterity problems, transportation lack to secure food.

  3. Cognitive, Psychiatric & Social:  isolation, lack of transportation, depression, dementia, paranoia.  In LTC, depression and other psychiatric conditions account for nearly 60% of involuntary weight loss.

  4. Restrictive Diets:  low sodium, low fat, diabetic, renal

  5. Oral Problems:  edentulous, poor fitting dentures, dental pain, oral sores, xerostomia (due to medications, Sjogren’s disease), dysgeusia

  6. Medical Conditions:  COPD, cardiac disease, dysphagias, Parkinsonism and other neurologic disorders, cancer, arthritis, infections, thyroid disorder, malabsorption syndromes, Helicobacter pylori, dyspepsia, alcoholism, and others.

  7. Polypharmacy as well as specific Offending Drugs: 
    Many medications have side-effects that can negatively impact nutrition directly or indirectly, and eventually lead to weight loss.  The following potential effects and associated medications are only a few examples:

    Anorexia – digoxin, spironolactone, furosemide, phenytoin, K+ supplements
    Nausea – digoxin, NSAIDs, opioids, some antibiotics
    Altered taste – metronidazole, clarithromycin, ACEIs, CCBs, metformin
    Dysphagia – bisphosphonates, NSAIDs, K+ supplements
    Early satiety –anticholinergics
    Hypermetabolism – thyroxine               
    Constipation      --  opioids, iron, diuretics
    Diarrhea – antibiotics

Also consider the potential risk for free circulating drug in undernourished persons taking medications that are highly protein bound such as digoxin.

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VII.  SCREENING AND ASSESSMENT

  1. Screening

    Nutritional screening tools are general survey, questionnaire, checklist or scaled instruments to identify individuals in a group of older adults with undernutrition or at potential risk. They can be self-administered, volunteer or professionally administered.  Screenings may lead to individual nutritional assessments to diagnose and treat persons with undernutrition.  Seven criteria have been established for screening tool selection: 1) simple– easy to use and interpret; 2) acceptable to the older adult; 3) accurate 4) cost – benefits equal to or exceed cost; 5) reliable; 6) sensitive; and 7) specific.

    The Nutrition Screening Initiative (NSI) was developed to address the prevalence of malnutrition among older adults; it was a collaborative effort among the AAFP (American Academy of Family Physicians), the ADA (American Dietetic Association), and others.  Two of the tools cited below (DETERMINE and NMA)  were among the many outcomes of the NSI.
    1. DETERMINE: a checklist of warning signs of poor nutrition. 

Disease
Eating Poorly
Tooth Loss/Mouth Pain
Economic Hardship
Reduced Social Contact
Multiple Medications
Involuntary Weight Loss / Gain
Needs self-care assistance
Elder above age 80

The questions in the screening tool flow out of the DETERMINE warning sign mnemonic above.  The questionnaire and scoring criteria can be found at:
http://geridoc.net/nutrition.html  or nutritionandaging.fiu.edu/downloads/NSI_checklist.pdf

  1. MNA:  Mini-Nutritional Assessment is both a screening and assessment tool.  The MNA-SF (short form) is only a screen and is Part I of the two-part MNA tool.  The MNA has been called the best screening tool for use in older adults.  More detailed Information and the tool itself can be viewed at:  http://www.merck.com/media/mmpe/pdf/Figure_002-1.pdf

    http://www.mna-elderly.com/forms/mna_guide_english.pdf  (color detailed MNA directions)

  2. SCALES:  this tool has been cross-screened with the MNA and is useful in outpatient settings.  Available online at: http://www.merck.com/mrkshared/mmg/tables/61t3.jsp
  1. Assessment
  1. Detailed History and Exam
    • Diet and weight history, Medical, Medications, Psychiatric, Social (financial resources, bereavement, isolation, alcohol), Functional
    • Potentially Reversible Causes?
      • Meals on Wheels mnemonic in LTC

        Medications
        Emotional (depression)
        Anorexia tardive (late life nervosa)/Alcoholism
        Late life paranoia
        Swallowing disorders

        Oral problems
        Nosocomial infections (H. pylori, C. Diff)

        Wandering (& other dementia related behavior [DRB] )
        Hyperthyroidism / Hypoadrenalism / Hypercalcemia
        Enteric problems (malabsorption)
        Eating Problems
        Low salt diet
        Stones (cholelithiasis)

  2. Clinical Signs of Undernutrition
    • Muscle wasting, loss of fat stores
    • Percentage of IWL (involuntary weight loss)
      • 5% in 30 days
      • 10% in 6 months or less
    • BMI < 21 [severe if <19]
    • Weight < 80% IBW (ideal body weight)
    • Anthropometrics
      • Mid-arm circumference and Triceps skin fold measurements
      • < 10th percentile on normative values table
      • May yield more useful information over time using the patient as his/her own control
      • Not commonly done unless part of Nutrition Support Team or Registered Dietician Consult

    • Clinical signs of Dehydration
      • Reduced urine output
      • New or worsened orthostatic vital signs
      • Confusion
      • Xerostomia
        • “Ropey” saliva
        • Buccal mucosal dryness
        • Dry, furrowed or scrotal tongue
          • moist scrotal tongue is normal variant
        • Caution:  patients with Sjogren’s disease often have xerostomia as well as dryness of other mucous membranes (depending on severity)

  3. Biochemical Signs of Undernutrition
    • Total Cholesterol (TC) < 160  [late sign]
    • Serum Albumin < 3.5
      • half-life 2-3weeks
    • Pre-albumin < 15
      • half-life 2-3 days
    • The combination of BOTH low total cholesterol and serum albumin confers even greater risk of increased morbidity or mortality.
      • Low Albumin and Pre-albumin have prognostic significance but are neither sensitive nor specific  for malnutrition; they may actually be markers of inflammatory status due to cytokine activity
    • Serum Transferrin < 180
    • Other testing that may be useful in searching for potentially reversible underlying causes:  CBC, FOBT, (fecal occult blood testing), TSH
  1. Treatment
  1. Address the underlying cause when possible
    • Example:  treat the pain of arthritic hands (or any significant pain), depressive pathology, GERD, tremor, dental appliance fit, oral topical analgesics, drug contributions, artificial saliva, etc
    • Obtain Registered Dietician consult
    • Estimate energy requirements
    • Eliminate restrictive diets
      • Involve patient in food preferences
      • Use calorie dense foods

  2. Liquid Supplements between meals
    • Recall that supplements usually do not work in cachexias (hypermetabolic states)
    • Little benefit if given with meals

  3. Smaller portions & more frequent eating rather than traditional 3 meals

    Consider disease specific recommendations in select cases, such as switching substrate to low carbohydrate (CHO) and higher balanced-fat calories in patients with COPD.  CHO substrate metabolism typically results in increased CO2 production which can be burdensome on the lungs to try to exhale it.  The Respiratory Quotient (RQ) is a ratio of C02 production to O2 consumption.  The RQ for CHO metabolism is higher than that for fat or protein.  Commercially available low CHO and balanced high-fat nutritional supplements are available for patients with COPD.  (Examples:  Nutren ®, Pulmocare ®.)  These types of products may be helpful in COPD patients who are hypercapnic.  They also provide denser calories which is usually beneficial in persons with COPD since the work of breathing (WOB) alone can be very costly in terms of caloric expenditures.  Low BMI in patients with COPD is associated with higher mortality. 

  4. Consult SLP (speech language pathologist) for evaluation and management recommendations regarding dysphagia in any one or more of the four phases of deglutition.

  5. Carefully consider Orexigenic Drugs (so-called appetite stimulants)
    • Antidepressant
      • Mirtazapine:  (Remeron ®) antidepressant with some orexigenic properties. Sedating.  Start with low dose. Give at bedtime.  Common.
    • Anabolic Steroid
      • Testosterone:  Low levels correlate with male sarcopenia.  May be reasonable in undernourished men with low testosterone levels.  Not commonly tried.
      • Nandrolone:  renal failure nutrition.  NO LTC studies.
      • Oxandrolone:  burn patients.  NO LTC studies.
    • Progestational Agent
      • Megestrol Acetate:  (Megace ®) 400 to 800 mg increases appetite (food intake) and weight.  Weight gain is fat.  Risks:  DVT, markedly decreased testosterone levels, adrenal suppression, edema, constipation, hyperglycemia.  Use in ambulatory persons with cytokine excess.  If used in men, may consider use concurrently with testosterone.
    • Cannabis Agent
      • Dronabinol:  (Marinol ®) increased desire for food and hedonia eating.  Known to be effective in cancer and AIDS.  Antiemetic and analgesic benefits.  Reduction of aggression in Alzheimer’s patients.  Considered by some as ideal medication in palliative and end-of-life care. Avoid use in dysphoric patients. Side-effects may include delirium, comnolence, and ataxia.
    • Prokinetic Agent
      • Metoclopramide:  (Reglan ®) useful in gastroparesis.  May cause dystonia and precipitate Parkinsonism symptoms.
    • Antihistamine
      • Cyproheptadine: (Periactin ® no longer available as brand).  May stimulate appetite.  NOT appropriate in older adults to due anticholingergic effects and vertigo.
    • Other drugs associated with weight gain:
      • Tricyclic antidepressants (not recommended in elderly)
      • Glucocorticoids – side effect of use
      • Antipsychotic agents – monitor diabetics closely especially with Haloperidol, Olanzapine, and Risperidone
      • Omeprazole – may cause weight gain in some persons

  6. Nutrition Tubes
    • commonly called “feeding tubes” although there is nothing about these tubes that is “feeding.”  The term “feeding” carries heavy emotional and social connotations.  Rather, these are medical devices used for a medical treatment that allows for an alternative provision of nutrition (aka: artificial nutrition).
    • May be appropriate in dysphagia given the patient’s full medical context and QOL (quality of life) otherwise
    • They are not recommended in end-stage dementia's by the American Medical Directors Association (AMDA) and many other organizations.
    • The American Geriatrics Society (AGS) Foundation has an educational forum for families: "Tube Feeding Decisions for People with Advanced Dementia" available online at: http://www.healthinaging.org/public_education/pef/tube_feeding.php
    • They are not appropriate if the primary purpose is to prevent aspiration pneumonia
      • No research demonstrating PEG (percutaneous endoscopic gastrostomy) tubes prevent pneumonia
      • SBFT ** Small bore flexible nutrition tubes placed either nasoenterally or nasogastrically may be appropriate for short-term nutrition [4-6 weeks]; sometimes called, “fine, pliable” tubes.
      • ** Note:  the term “Dobbhoff” should not be used since it is only one manufacturer’s brand name. Dobbhoff was an early mercury-weighted nasoenteral tube.  Most current weighted nasoenteral tubes use tungsten, not mercury.  Other brand names include: Flexiflo ®, Nutriflex ®, and Corpak®.

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Nutrition Case Study #1: "Good Grief! What does Digoxin have to do with it?"

Mary Hobbs

Mary Hobbs is an 82 year-old white female widow who lives in an Independent Living (IL) apartment of a large continuing care retirement community (CCRC). She has support from a daughter and two daughters-in-law who look in on her regularly. She is followed for chronic atrial fibrillation. Her only medication is digoxin 0.25 mg every day. She is seen in the CCRC clinic about every three months for regular follow-up. When last seen she weighed 130 lbs and was noted to be in good health. She presents today, accompanied by her daughter, for her routine visit and states all is going well. However, shortly after her last visit her son died and she has been very sad and tearful. She denies a poor appetite, but a of weight loss of 7 lbs. since her last visit is noted. During the interview, she seems to fixate on her son's death and how difficult it is for her to accept, but says she will just have to adjust. Her daughter is quite concerned about her mother, noting increasing isolation and anorexia. She also relates that over the past 2 years her mother has been more forgetful and less motivated. These symptoms worsened following the death of her son. There is a congregate meal opportunity in either of two dining room options in the facility, but Mrs. Hobbs has never participated and refuses to do so presently. The family prepares meals and delivers them to Mrs. Hobbs, but frequently notice they are not being eaten. They also take her grocery shopping where she selects foods of her preference. Much of this goes uneaten. They have noticed when she comes to their homes for a meal or to stay overnight, her appetite is good and her sprits are much better. Mrs. Hobbs has been invited to live with her daughter, but refuses to leave her own apartment and is insistent about remaining independent.

Questions:

  1. What risk factors are present for nutritional compromise and dehydration in Mrs. Hobbs?

Physical examination reveals that Mrs. Hobbs weighs 123 lbs and is 5 feet 5 inches tall. Her sitting VS are: blood pressure 130/80, pulse 80 irregula; standing BP changes to 118/72 and pulse of 90. HEENT exam reveals temporalis muscle atrophy. She is edentulous with apparently well-fitting dentures. No oral lesions are present. Tongue is midline with slight loss of papillae. Lungs are clear. Heart sounds are irregular with a grade Il/VI systolic murmur. The abdomen is soft and nontender. Bowel sounds are normal. Extremities are without edema. Fat stores seem adequate with no obvious muscle atrophy. Mental status examination reveals short-term memory loss, poor concentration, and poor insight. There are no focal neurologic deficits. Laboratory: electrolytes within normal limits; blood urea nitrogen 28; creatinine 0.8; glucose 120; calcium 9.1; serum albumin 3.2; hemoglobin 11.4; hematocrit 35.1 with normal MCV and MCHC. WBC count is 8.2 with normal differential. Serum iron within normal limits. Transferrin is 252, B12 300, folate 4.5, TSH 3.2, total T4 6.1.

Questions (continued)

  1. What additional information is needed to further assess her nutritional and hydration status?
  2. What interventions would be appropriate at this time?

Approximately 3 weeks after Mrs. Hobbs was seen, her daughter brings the patient to the emergency room. There she gives a history of near-syncope after some prolonged standing waiting for the CCRC activity bus to pick her up. In the emergency room she is found to weigh 118 pounds. Her blood pressure supine is 120/76, pulse 86 irregular, which drops to 100/60 and pulse increases to approximately 100 irregular upon standing. No history suggesting infection. No history of nausea or vomiting. No cardiac symptoms. Laboratory: BUN 30, creatinine 1.3, digoxin level 1.8, electrolytes are within normal limits, glucose 100. No significant change in hemoglobin/hematocrit. Urinalysis: specific gravity 1.024, no protein, no glucose. WBC count, 5 to 7. No RBC's. Electrocardiogram: atrial fibrillation approximately 80 to 90. No change from previous ECG. She is treated with intravenous fluids in the emergency room and feels better after 500 cc of intravenous (IV) D5 0.5 normal saline. Her orthostasis resolves and she is discharged from the emergency room with follow-up planned in 2 days. Her digoxin dose is reduced to 0.125 mg.

Questions (continued)

  1. What further management issues are now present?
  2. What would be the benefits of a home visit in this patient?
  3. What interventions would you consider for her hydration maintenance, improved nutritional intake, and concern about grief, depression, and/or early dementia?

 

Nutrition Case Study #2:   "Aren't apples good for you?"

Ann Jones

Ann Jones is a 67 year old white woman. She is single and has never been married. She has had difficulty with weight management over her lifetime. Currently, she is being treated with glypizide for Type II diabetes mellitus. She is a non-smoker and does not drink alcohol. She tries to follow a diabetic diet, but admits she is somewhat non-adherent. Her mother died in her late 60s due to a myocardial infarction and also had diabetes mellitus.  Mrs. Jones is 5 ft 5 in. tall and weighs 190 pounds (BMI = 31.6). She is noted to resemble an apple in her body shape (most of her weight being located in her neck, torso, and abdomen). Vital signs are as follows: BP 150/90 mm Hg; pulse 80 beats/min and regular; and respirations 16 per minute.  Physical examination findings reveal central obesity with normal musculature of the extremities. Cardiovascular examination is within normal limits. There is no evidence of end organ damage by the diabetes mellitus. Laboratory: postprandial glucose is 190; serum albumin is 3.2; serum cortisol is normal; and serum cholesterol is 158.

Questions:

  1. Is Mrs. Jones obese?
  2. What are Mrs. Jones' risk factors for cardiovascular disease?
  3. Does Mrs. Jones' body shape contribute to her health problems?
  4. Is Mrs. Jones nutritionally compromised?

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Nutrition Case Study #3: "Increase the dietary fat content – are you kidding?  What would my husband’s cardiologist say? "

Harold Hubbs

Mr. Harold Hubbs is an 80 year-old caucasian male admitted to hospital with severed COPD.  He has chronic anorexia and a 21 pound weight loss (12%) the past 8 weeks.   His height is 68 inches and admit weight is 154 pounds. He is pursed-lip breathing and sitting in tripod position.

PMH:  CHF, HTN, Diverticulitis, CAD, Myocardial Infarction 18 months ago 
Current  Meds:  ASA, Albuterol, Azmacort, Ipratropium, Prednisone, Vasotec, Lasix, KCL, Lisinopril
Diet:  Low Fat, low Na+ per cardiology (diligently adhered to by his wife when preparing his food); Ensure Plus with meals.
Labs:    Albumin 1.9; Total Cholesterol 87, Hgb 8.5 

By the 4th hospital day he became febrile, reported oral pain (oral candidiasis was noted on exam), and had developed pseudomenbranous colitis diarrhea occurring several times daily.

Questions:

  1. What are major indicators of malnutrition in this patient? 
  2. What are the likely consequences of this man’s nutritional status?
  3. What interventions might you consider?
  4. Do you have any nutritional recommendations specific to the COPD?
  5. Are there any non-nutritional interventions that should be addressed this point?

Five additional abbreviated Nutrition Cases will be reviewed during the facilitated discussion session as time permits.

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