Instructor: Sharee A. Wiggins, NP, Post-MS(N), ARNP, BC-GNP, BC-ANP
Module Developed by: Sharee A. Wiggins, NP 2007; Revised 2009
Cases #1 and #2 by 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
C. Knowledge
D. Skills
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, BChRecommended Reading:
Levenson, S. (2002, September). Changing perspectives on LTC nutrition and hydration. Caring for the Ages; 10-14. Accessed online: July, 2009 at: http://www.amda.com/publications/caring/september2002/nutrition.cfm?printPage=1&
[Note: this article has a link to PART II at the bottom of the page for PART I]Li, I. (2002, April 15). Feeding Tubes in Patients with Severe Dementia. American Family Physician,65(8). Available online at: http://www.aafp.org/afp/20020415/1605.html
Merck. Protein-energy undernutrition. Manual of Geriatrics. Accessed July, 2009 online at: http://www.merck.com/mrkshared/mmg/sec8/ch61/ch61a.jsp
Morley, J. E., & Thomas, D. R. (2003, June). Development of guidelines for the use of orexigenic drugs in LTC. Supplement. Annals of Long Term Care. Accessed July, 2009 online at: http://www.annalsoflongtermcare.com/attachments/1057151324-Orexigenic.pdf
- 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
Additional Resources:
- AMDA (American Medical Directors Association). (2001). Altered nutritional status: Clinical Practice Guideline.
- Coutin, I. B., Kejriwal, K., Wilde, V. C., Summers, M., Patel, N., & Apted, P. (2007, January/February). Tube feeding and pneumonia: An unhappy couple. Long Term Care Interface; 21-25.
- Food Research and Action Center. Elderly Nutrition Program Fact Sheet. Accessed May, 2007, online at: http://www.frac.org/pdf/ENPfactsheet.PDF
- Food Security Institute Center on Hunger and Poverty. The Heller Graduate School for Social Policy and Management. Brandeis University. (2003, February). Hunger and Food Insecurity Among the Elderly. Accessed May, 2007 online at: http://www.centeronhunger.org/pdf/Elderly.pdf
- Guigoz, Y. (2006). The Mini Nutritional Assessment (MNA) review of the literature: What does it tell us? Journal of Nutrition, Health and Aging; 10(6):466-487.
- Guigoz, Y., Lauque, S., & Vellas, B. J. (2002). Identifying the elderly at risk for malnutrition: The Mini Nutritional Assessment. Clinical Geriatrics Medicine;18(4):737-757.
- Lewko, M. Chamseddin, A., Zaky, M., Birrer, R. B. (2003, November). Weight loss in the elderly: What’s normal and what’s not. P&T; 734-739.
- Rajesambhaji, B., Golden, A. G., Silverman, M. A., & Musson, M. (2007, January-February). Nutritional supplements do not always work. Long-Term Care Interface; 21-25.
- Ranhoff, A. H., Gjoen, A. U., & Mowe, M. (2005). Screening for malnutrition in elderly acute medical patients: The usefulness of MNA-SF. Journal of Nutrition, Health and Aging; 9(4):221-225.
- Wilson, M. G., & Morley, J. E. (2003). Physiology of aging. Invited Review: Aging and energy balance. Journal of Applied Physiology; 95:1728-1736.
F. Module Content: Nutrition, Undernutrition, Malnutrition
D. Cases
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
Protein-Energy Malnutrition (PEM): presence of both clinical and biochemical changes consistent with undernutrition.
- Ambulatory/Community Dwelling – 1% to 15%
- Hospitalized – 35% to 65%
- Institutionalized – 24% to 60
- Ambulatory/Community Dwelling – 15%
- Hospitalized – 20% to 65%
- Institutionalized – 5% to 85%
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.
- 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. For more information, go to the Food Stamps for the Elderly Resource Center at: http://www.frac.org/html/news/fsp/fselderlycenter.htm
- 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). Additionally, ENP volunteers can provide nutrition screening, education and meal-planning counseling. 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.
- 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.
- Functional Deficits: visual impairments, immobility, tremors, dexterity problems, transportation lack to secure food.
- 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.
- Restrictive Diets: low sodium, low fat, diabetic, renal
- Oral Problems: edentulous, poor fitting dentures, dental pain, oral sores, xerostomia (due to medications, Sjogren’s disease), dysgeusia
- Medical Conditions: COPD, cardiac disease, dysphagias, Parkinsonism and other neurologic disorders, cancer, arthritis, infections, thyroid disorder, malabsorption syndromes, Helicobacter pylori, dyspepsia, alcoholism, and others.
- Polypharmacy as well as specific Offending Drugs: numerous drug classes may be implicated in appetite reduction. Common culprits include: ACEIs (angiotensin converting enzyme inhibitor), SSRIs (selective serotonin reuptake inhibitor), Antibiotics, AEDs (anti-epileptic drugs), Digoxin, Beta-blockers, Calcium Channel blockers, Diuretics, NSAIDs (non-steroidal anti-inflammatory drug), Opioids, H2-blockers, and Antipsychotics.
Also consider risk of potential free circulating drug in undernourished persons taking medications that are highly protein bound such as digoxin.
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 80The 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 http://geriatricsreviewsyllabus.org/content/agscontent/grs6nutr.htm
- 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)
- 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
- 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)- 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)
- Biochemical Signs of Undernutrition
- Total Cholesterol (TC) < 160 [late sign]
- Serum Albumin < 3.5
- may actually be a marker of inflammatory status due to cytokine activity
- half-life 2-3weeks
- Pre-albumin < 15
- same comment as for Albumin above
- half-life 2-3 days
- Serum Transferrin < 180
- Other testing that may be useful in searching for underlying causes: CBC, FOBT, TSH
- 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
- Liquid Supplements between meals
- Recall that supplements usually do not work in cachexias (hypermetabolic states)
- Little benefit if given with meals
- 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.
- Consult SLP (speech language pathologist) for evaluation and management recommendations regarding dysphagia in any one or more of the four phases of deglutition.
- 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, use concurrently with testosterone. Recommended maximum use is 3 months.
- 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
- 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; Sometimes called, “fine, pliable” tubes.
- ** Note: the term “Dobbhoff” should not be used since it is a manufacturer’s brand name for an early mercury-weighted nasoenteral tube. Most current nasoenteral tubes are weighted with tungsten, not mercury. (Examples: Flexiflo ®, Nutriflex ® etc).
Mary Hobbs
Mary Hobbs is an 82 year-old white 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 3 months ago, she was noted to be in good health. She presents today 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 decrease of 7 lbs. since her last visit is noted. Her last recorded weight is 130 lbs. During the interview, she seems to fixate on her son's death and how difficult it is for her to accept. She says she will just have to adjust. However her daughter, who has accompanied Mrs. Hobbs, states she is quite concerned about her mother. In particular, she notes increasing isolation and weight loss for her mother. She also relates that over the past 2 years her mother has been more forgetful and less motivated. These symptoms have gotten much worse after 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:
Physical examination reveals that Mrs. Hobbs weighs 123 lbs and is 5 feet 5 inches tall. Her blood pressure is 130/80, pulse 80 irregular, which drops to 118/72 with pulse of 90 upon standing. Head, eyes, ears, nose, and throat examination 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: no 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)
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. 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. She describes feeling weak and light-headed upon standing. She describes feeling weak and light-headed upon standing. Physical examination reveals her eyes to be sunken and mucous membranes dry. No evidence of 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)
A home visit is made in follow-up the next week. There is adequate food available in her apartment. Mrs. Hobbs remains depressed with early dementia and still resists leaving her apartment to go to meals in the congregate dining room. She also refuses to move in with her daughter. She is willing to go to the families' homes to eat meals several times a week and has agreed to stay with her daughter on weekends to help with her 5 year-old grandchild. A water prescription of 2 qt of fluid per day is given, and a reminder sheet is placed on the refrigerator to help Mrs. Hobbs keep track of her fluid intake. She has agreed to participate in group therapy to assist in her bereavement over the loss of her son. It is thought that an antidepressant at this time is not warranted and could potentially make matters worse by increasing her confusion, contributing to anorexia, exacerbate her orthostasis, or produce xerostomia. Her depressive symptoms will be closely followed and if persistent or worsen, pharmacologic treatment will be started. She is seen after another 2 weeks and 6 weeks. She weighs 127 lbs at the end of that time. She is noted to be in better spirits and states her appetite is better after the change in the digoxin dose. Her family checks on her consumption when they come to visit. Mrs. Hobbs remains committed to maintaining her own apartment and the family is less concerned about allowing her to do so.
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:
Abbreviated Nutrition Case #s 3, 4, 5, 6, 7, and 8 will be reviewed during the facilitated discussion session as time permits.
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