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8/4/2019 Nutrition and Malnutrition 112806
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Nutrition and Malnutrition inthe Elderly
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Goals, Objectives, Standards
Goals Appreciate the scope of nutritional assessment and intervention
in the medical care of the elderly
Objectives Practice use of nutrition screens Practice implementation of nutritional interventions Code correctly for evaluation and treatment
Standards Use DETERMINE nutritional screen Use Mini Nutritional Assessment
Compute Body Mass Index Compute Ideal Body Weight Compute Energy Needs
Compute Protein Needs
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Case Phase 1: Evaluation of Outpatient
82 yr female on a fixed income lives at homealone and is dependant upon friends as fortransportation. She has HTN, CAD, CRF, and
OA all modestly controlled on HCTZ, ACE1,TNG, beta-blocker, and acetaminophen. Herchief complaint is having trouble dressingherself secondary to L shoulder pain. You
note a 10 pound weight loss since her lastvisit six months ago.
What do you do next?
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Demographics
Malnutrition
Independent 0-6%
Skilled Care 2-27%
Hospital 10-30%, up to 75%
Stay is longer with more malnutrition
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MACRONUTRIENTS I
Water 8 x 8 oz/d
30ml/kg/d or 1ml/kcal eaten
Carbohydrates 55-60% total kcal/d carbs from whole grains
Proteins 1 to 1.5 gm/kg/d
Fats 4 gm/d
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Micronutrients
Vitamins, Co-factors
Minerals
Trace Elements
Multivitamin
Multivitamin
Multivitamin
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Anthropometrics I
Clinical
10 pound loss in six months or weight < 100 lbs
Relative Risk of Death 2.0
PPV of malnutrition = 0.99
Minimum Data Set
Weight loss >= 5% past month
Weight loss >= 10% past six months
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Anthropometrics II
BMI : Body mass index = weight (kg) / height (m2) Correlated to nutrition status, morbidity, mortality
18.4 and lower greater risk malnutrition and related diseases
30 and higher the greater risk for DM, CAD, HTN, OA, CA
National Practice Standard = Compute @ each office visit
Underweight = 30
Extreme Obesity >= 40
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BMI Table http://www.nhlbi.nih.gov/guidelines/obesity/bmi_tbl2.htmBMI 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35
Height Body Weight (pounds)
58 91 96 100 105 110 115 119 124 129 134 138 143 148 153 158 162 167
59 94 99 104 109 114 119 124 128 133 138 143 148 153 158 163 168 173
60 97 102 107 112 118 123 128 133 138 143 148 153 158 163 168 174 179
61 100 106 111 116 122 127 132 137 143 148 153 158 164 169 174 180 185
62 104 109 115 120 126 131 136 142 147 153 158 164 169 175 180 186 191
63 107 113 118 124 130 135 141 146 152 158 163 169 175 180 186 191 197
64 110 116 122 128 134 140 145 151 157 163 169 174 180 186 192 197 204
65 114 120 126 132 138 144 150 156 162 168 174 180 186 192 198 204 210
66 118 124 130 136 142 148 155 161 167 173 179 186 192 198 204 210 216
67 121 127 134 140 146 153 159 166 172 178 185 191 198 204 211 217 223
68 125 131 138 144 151 158 164 171 177 184 190 197 203 210 216 223 230
69 128 135 142 149 155 162 169 176 182 189 196 203 209 216 223 230 236
70 132 139 146 153 160 167 174 181 188 195 202 209 216 222 229 236 243
71 136 143 150 157 165 172 179 186 193 200 208 215 222 229 236 243 250
72 140 147 154 162 169 177 184 191 199 206 213 221 228 235 242 250 258
73 144 151 159 166 174 182 189 197 204 212 219 227 235 242 250 257 265
74 148 155 163 171 179 186 194 202 210 218 225 233 241 249 256 264 272
75 152 160 168 176 184 192 200 208 216 224 232 240 248 256 264 272 279
76 156 164 172 180 189 197 205 213 221 230 238 246 254 263 271 279 287
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BMI: NIH Recommendations
Clinicians should measure BMI and offer obesepatients intensive counseling and behavioralinterventions.
The National Institutes of Health provides a BMIcalculator at www.nhlbisupport.com/bmi and a tableat www.nhlbi.nih.gov/guidelines/obesity/bmi_tbl.htm.
The Centers for Disease Control and Prevention
provides a BMI calculator atwww.cdc.gov/nccdphp/dnpa/bmi/calc-bmi.htm.
http://www.nhlbisupport.com/bmihttp://www.nhlbi.nih.gov/guidelines/obesity/bmi_tbl.htmhttp://www.cdc.gov/nccdphp/dnpa/bmi/calc-bmi.htmhttp://www.cdc.gov/nccdphp/dnpa/bmi/calc-bmi.htmhttp://www.cdc.gov/nccdphp/dnpa/bmi/calc-bmi.htmhttp://www.cdc.gov/nccdphp/dnpa/bmi/calc-bmi.htmhttp://www.nhlbi.nih.gov/guidelines/obesity/bmi_tbl.htmhttp://www.nhlbisupport.com/bmi8/4/2019 Nutrition and Malnutrition 112806
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Anthropometrics III : Research tools
Skin fold and mid-arm circumference
Water Displacement
Bioelectrical Impedance
Dual Radiographic Absorptiometry
CT
MRI Total Body 40K
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Wasting and Cachexia Wasting - Severe weight
loss and diminishednutritional intake
Semistarvation
Reduced metabolic demand
Visceral protein sparing
Obvious weight loss
RA, CHF, COPD, HIV, Criticalcare without nutritional support
Cachexia - Inflammatory
cytokine mediated wasting
Semistarvation overlap
Increased metabolic demand
Visceral protein wasting
ECF incr masks weight loss
Limited response toantiinflammatory/anabolics
Nutritional intervention slowssemistarvation part
Marasmus, CA, HIV with oppinf, critical care withoutnutritional support, chronicorgan failure
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Protein-Energy Undernutriton
Clinical wasting + albumin < 3.5 gm/dl
> 1/3 hospital
< 1/3 NH
< 10% independent
Big cachexia overlap
Nutrition support
Treat underlying disease
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Failure to Thrive
Not a defined syndrome in the elderly
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DETERMINE Screening Tool
D isease
E ating poorly
T ooth loss, mouth pain
E conomic hardship
R educed social contacts
M ultiple medications
I nvoluntary weight loss or gain N eed for assistance in self-care
E lderly (age > 80)
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DETERMINE Your Nutritional Health Checklist. Nutrtion Screeining Initiative, a project of the American Academy of Family Physicians, the American Dietetic Association, and theNational Council on Aging, Inc., and funded in part by Ross Products Division,
DETERMINE Evaluation
Read the statements below. Circle the number in YES column for those that apply to you or
someone under your care. For each YES answer, score the number n the box. Total your
nutrition score.
I have an illness or condition that made me change the kind and/or amount of food I eat 2
I eat fewer than 2 meals a day 3
I eat few fruits or vegetables, or milk products 2 I have 3 or more drinks of beer, liquor, or wine almost every day 2
I have tooth or mouth problems that make it hard for me to eat 2
I dont always have enough money to buy the food I need 4
I eat alone most of the time 1
I take three or more different prescribed or over-the-counter drugs a day 1
Without wanting to, I have lost or gained 10 pounds in the last 6 months 2
I am not always physically able to shop, cook, and /or feed myself 2
Note: Scoring: 0-2 = good, 3-5 = moderate nutritional risk, 6 or more = high nutritional risk
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Mini-Nutritional Assessment (MNA)
Two Part
3 min screen
8 min diagnostic
Validated against measurable standards
Inclusive, Plenary
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MNA Part 1 Skill Session
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MNA Part 2 Skill Session
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MNA Study Results
Oral supplementation in skilled living elderlywith MNA 17-23.5 and < 17 with 1 can (400kcal) significantly increased:
calorie intake
MNA score about 3 points
Weight about 1.5 kg
Alzheimers Supplementation at 2 kg weight loss stabilizes
weight loss compared to controls
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Food Pyramids
MyPyramid.gov
Culturally distinct
More flexible
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MyPyramid.gov
Grains gold
Vegetables green
Fruits red
Oils yellow
Milk Blue
Meats + Beans Purple
Discretionary Calories
< 200 to 300 kcal
Exercise
30, 60, 90 rule
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Age Specific Recommendations
People over age 50.
Consume vitamin B12 in its crystalline form (i.e.,fortified foods or supplements).
Older adults, people with dark skin, andpeople exposed to insufficient ultraviolet bandradiation (i.e., sunlight).
Consume extra vitamin D from vitamin D-fortifiedfoods and/or supplement
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Nutrient-Nutrient/Drug Interactions
Numerous
Ca, Mg, Fe
Phytins (in fiber) Tannins (coffee, tea)
Bind drugs/nutrients
Bind drugs/nutrients Bind drugs/nutrients
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Drug-Nutrient Interactions I
Alcohol
Antacids
Antibiotics
Colchicine Digoxin
Diuretics
Isoniazid Levodopa
Laxatives
Zn, A, B1, B2, B6, B12, folate
B12, folate, Fe, kcal
K
B12 Zn, kcal
Zn, Mg, B6, K, Cu
B6, niacin B6
Ca, A, B2, B12, D, E, K
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Drug-Nutrient Interaction II
Lipid Binding Resins
Metformin
Mineral Oil
Phenytoin Salicylates
SSRI
Theophylline Trimethoprim
A, D, E, K
B12, kcal
A, D, E, K
D, folate C, folate
Kcal
Kcal folate
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Nutrient Treatment of Disease
Ca and Vit D for osteoporosis
B6, B12 for homocysteinosis
Antioxidants CAD, Macular Degeneration
Vitamin E failed for AD
Watch for overdosing of vitamins!
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Case Phase 2Outpatient Treatment
She responds to in-home physical therapyafter a steroid injection of her L shoulder. Shestarts to eat breakfast and uses a supplement
when her appetite is poor. Meals on wheelsbrings her one meal a day. She eats with afriend who cooks every Tuesday at lunch.She gains back 7 pounds.
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Case Phase 2 : Hospital Evaluation
Your patient falls and breaks her left hip. Shesurvives a L total hip replacement, butdevelops pyelonephritis with bacteremia at
the hospital. She is delirious. She loses 15pounds.
What do you do now?
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Nutrition Requirement Calculations 1
Estimated Energy Needs by Weight
25-30 kcal / kg body weight / day
Use 120% IBW for obese persons
Estimated Protein Needs by Weight Protein = (0.8-1.5) gm / kg body weight / day
Use IBW for obese persons
May need to be higher (2.0-3.0) for stressed andor very malnourished persons.
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Nutrition Requirement Calculations 2
Harris-Benedict Basal Estimated BasalEnergy Expenditure (BEE)
Male BEE = 66 +(13.7 x weight in kg) + (5 x
height in cm) (4.7 x age) Female BEE = 665 +(9.6 x weight in kg) + (1.8 x
height in cm) (4.7 x age)
Multiply by 1.00 (non-stressed) to 1.50 (stressed)
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Laboratory Evaluation
Albumin < 3.8 g/dl Lacks sensitivity and specificity
May decline very slightly with age
Negative acute phase reactant
Prealbumin Shorter half-life than albumin
No more predictive
Cholesterol < 160 mg/ml Indicates underlying serious disease in community, hospital
and NH patients
Total Lymphocyte Count < 2000 cells/microliter
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Tube Feeding
3-7 days of 1-2 kcal/ml supplement Convert to PEGE for long term use
1500-2400 ml per day to achieve water,
protein, calorie goals Start full strength, increase rate
Measure residuals, convert to bolus feeds
Supplement enzymes
Treat diarrhea
Deal with aspiration
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TPN
For non-functioning GI tract
No EMB studies in elders
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Case Phase 2: Hospital Treatment
After pulling out her NG tube every shift for24 hours, she is given TPN through hercentral line. After 48 hours, she is dyspneic,
hypoxic, and edematous. What do you do now?
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Re-feeding Syndrome
Syndrome of
hypophosphatemia
hypomagnesemia
fluid retention
about 3 days into re-feeding
Most pronounced with parenteral nutrition
Occurs with oral re-feeding as well
More severe with worse malnutrition Frequent subclinical presentation
Reduce re-feeding rate for three days to treat
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Case Phase 3: Skilled Facility Evaluation
She recovers from bacteremia, and since shecannot tolerate a rehab schedule due toresidual delirium and weakness is placed in
skilled care. While there, she does poorly inPT/OT. Has restricted diet order for CHF. Onnarcotics, anxiolytics. She is depressed,constipated, requires 1-2 person assists forADLs. She has no appetite.
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Anorexia
Drugs
Anemia
Uremia
Liver Disease Dry Mouth
Pain
Cancer
Inflammation
Psychiatric Illness
Bowel Disease Constipation
Malnutrition
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Anorexia : Appetite Stimulation
Food Appearance
Salt
Sugar
Social Contact Feeding
Ambience
Familiarity Drugs
Ghrelin, other hormones
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Anorexia : Pharmacologic Support
Mirtazipine probably works
Cannabis, Cannabinoids, Tetrahydrocannabinol and its derivatives No therapeutic effect or use in medicine
Ritalin Unsure, probably in depression
Estrogens/Progestins/Thalidomide Probably risk of DVT is too high for routine use
Corticosteroids Especially in cancer, hematologic, neurologic
Prokinetics Cyproheptadine Hydrazine sulphate no utility Dronabinol Antiserotonergic drugs Branched-chain amino acids, Eicosapentanoic acid Melatonin
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Sarcopenia of the Elderly
Age related loss of skeletal mass
Type I fibers spared
Type II loss of number and size
Questions: Sedentary
Dietary
Hormonal Neurologic
Sex hormonal
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Case Phase 4
Recovers
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ICD-9 Codes
Malnutrition 1st degree (mild) 263.1 2nd degree (moderate) 263.0 3rd degree (severe) (protein calorie) 262 From neglect 995.84 Causes problems for NH
Hypoalbuminemia / Hypoproteinemia 273.8 Protein Deficiency / Kwashiorkor 260 Marasmus 261
Causes problems for NH
Senile Marsmus 797 Intestinal Marasmus 569.89 Lack of Food 994.2
Nutritional Deficiency, particular, specify 269.9 Undernourishment/Undernutrition 269.9 Weight loss (cause unknown) 783.21 Failure to thrive 783.7
Causes problems for NH
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Treatment of Malnutrition
Ease dietary restrictions
Supplements
Foods
Enhanced Milk or Soy based products
Drugs
Supportive Therapies
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Summary
Malnutrition is prevalent in the elderly
Reproducible assessment is available
Intervention prevents morbidity and mortality
Supplements have a role in therapy
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Bibliography
Cobbs EL, Dithie EH, Murphy JB, eds. Geriatrics Review Syllabus: A Core Curriculum in Geriatrics Medicine. 5thed. Malden, MA: Blackwell Publishing for the American Geriatrics Society; 2002.
MyPyramid.gov United States Department of Agriculture
Screening for Obesity in Adults. What's New from the USPSTF?AHRQ Publication No. 04-IP002, December2003. Agency for Healthcare Research and Quality, Rockville, MD.http://www.ahrq.gov/clinic/3rduspstf/obesity/obeswh.htm
http://www.mna-elderly.com/ Cornali, Cristina, Franzoni, Simone, Frisoni, Giovanni B. & Trabucchi, Marco (2005)
ANOREXIA AS AN INDEPENDENT PREDICTOR OF MORTALITY.Journal of the American Geriatrics Society53 (2), 354-355.doi: 10.1111/j.1532-5415.2005.53126_4.x
Visvanathan, Renuka, Macintosh, Caroline, Callary, Mandy, Penhall, Robert, Horowitz, Michael & Chapman, Ian (2003)The Nutritional Status of 250 Older Australian Recipients of Domiciliary Care Services and Its Association with Outcomes at 12 Months.Journal of the American Geriatrics Society51 (7), 1007-1011.doi: 10.1046/j.1365-2389.2003.51317.x
http://www.nhlbi.nih.gov/guidelines/obesity/bmi_tbl2.htm
Persson, Margareta D., Brismar, Kerstin E., Katzarski, Krassimir S., Nordenstrm, Jrgen & Cederholm, Tommy E. (2002) Nutritional Status UsingMini Nutritional Assessment and Subjective Global Assessment Predict Mortality in Geriatric Patients. Journal of the American GeriatricsSociety50 (12), 1996-2002.doi: 10.1046/j.1532-5415.2002.50611.x
Journal of the American Geriatrics SocietyVolume 52 Issue 10 Page 1702 - October 2004doi:10.1111/j.1532-5415.2004.52464.x
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Bibliography
Hematol Oncol Clin North Am. 2002 Jun;16(3):589-617.Related Articles, Links
Update on anorexia and cachexia.
Strasser F, Bruera ED.
Department of Palliative Care and Rehabilitation Medicine, MD Anderson Cancer Center, 1515 Holcombe Boulevard, Box 0008, Houston, TX 77030, USA
Cancer Surv. 1994;21:99-115.Anorexia and cachexia in advanced cancer patients.
Vigano A, Watanabe S, Bruera E.
Palliative Care Program, Edmonton General Hospital, Canada.CA Cancer J Clin. 2002 Mar-Apr;52(2):72-91.
Cancer anorexia-cachexia syndrome: current issues in research and management.
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