Date post: | 05-Feb-2018 |
Category: |
Documents |
Upload: | vuongkhanh |
View: | 216 times |
Download: | 0 times |
UNDERNUTRITION AND WEIGHT LOSS IN THE ELDERLY
NAUSHIRA PANDYA M.D.,C.M.D.Chair and Associate ProfessorDepartment of Geriatrics Director, Geriatric Education Center, NSU COM
CECILIA ROKUSEK Ed.D., R.D.Professor of Family Medicine and Public HealthExecutive Director, Geriatric Education Center, NSU COM
The scope of the problemMode of living Prevalence(%) References
Free-living 5 Dept of Health and Social Sec, UK
7 Dept of Health and Social Sec, UK
5 Blondel-Cynober et al.2 Lowink et al.1-4 Cederholm et al.
Hospital 39 Cederholm et al.59 Rapin et al.50 Alix.22 Volkert et al.
Nursing home 30-60 Rudman et al.10-85 Kerstetter et al.
Change in food intake over the life span-NHANES III
0
500
1000
1500
2000
2500
3000
3500
20-29 30-39 40-49 50-59 60-69 70-79 >80
Age(y)
(Kca
l)
45
46
47
48
49
50
51
52
(% o
f ene
rgy)
Kcal MenKcal WomenCarbs
NHANES 111 DATA
4% of persons between 60-69 yr were unable to prepare their meals or walk around23% of persons over 80 yr were unable to prepare their meals and 17% were unable to walkGFR < 30ml/min/1.72m2 major risk factor for malnutrition in older adults30-40% of patients on dialysis were malnourished
Marwick C. JAMA 1997;227
Normal aging changes, physical, psychological and social precipitants
AnorexiaWeight loss
Malnutrition
Depression
Cognitive dysfunction
Social withdrawal
Isolation Giving up DEATH Egbert
Barriers to adequate nutritional management of older patients by physicians
Inadequate training in recognizing protein calorie undernutritionUnawareness that protein calorie undernutrition may be the presenting feature of many treatable diseases in the elderlyUnawareness of currently available treatment options
Morley
Conditions associated with protein-energy undernutrition in the elderly
Immune deficiency, increased infection, pneumoniaPressure ulcersPoor wound healingAnemiaFallsCognitive deficits, increased deliriumOsteopenia, hip fracturesAltered drug metabolismSarcopenia, weakness, fatigueOrthostatic hypotension and dehydrationNon-thyroidal illnessDecreased maximal breathing capacityDecreased cardiac output
Predictors of nutritional disorders and disability
Katz ADL index scoreSerum albumin levelPatient’s current weight as percentage of usual weightNumber of prescribed medications takenPresence of renal disease (BUN level > 30)Individual’s incomePresence of one or more decubiti (grade II or higher)DysphagiaMid-arm muscle circumference
Sullivan DH
Nutrition and immunity in the elderly
Infections are more common in the undernourished - especially pulmonaryCell-mediated immunity and delayed hypersensitivity declinesTotal lymphocyte count ↓ (< 800/mm3 reflects undernutrition)T cell proliferation ↓B lymphocyte proliferation Cytokine release ↓ (IL2 and IL1) - fever often absent, and inflammatory syndromes have prolonged evolution periods
CD4:CD8 ratio in undernourished patients who are HIV -
Micronutrient supplementation has been showed to restore T cell deficiency (zinc-thymulin, Vit E -?antioxidant)
Usual aging is associated with decrease in skeletal and visceral lean body mass (LBM), bone density, total body water, and increase in total fat
SARCOPENIA wasting of skeletal muscleLBM declines 19% in men and 12% in women (25-75y)Due to aging, inactivity, malnutrition, catabolic diseases (CHF, COPD, cancer, hyperthyroidism)
CACHEXIA is loss of both muscle and fatNot physiologicOccurs in malignancies and HIV disease Systemic inflammatory response
Outcomes of Severe Weight Loss in Older Persons
Increased hospitalizationIncreased length of hospital stayIncreased hospital costsDelayed recovery from surgeryIncreased mortality (weight loss in 6 mths in NH pts associated with 2 fold increase in likelihood of death- Yamashita et al. 2002)
Increased NH placement in older women (BMI < 21.4 Kg/m2 )
The assessment
Case 1A 73 yr old woman is noted to have a 10 lb involuntary weight loss at her annual physicalFood just does not appeal to her and she can’t be bothered with meals; she lives aloneShe has HTN, osteoarthritis, glaucoma, and T2 diabetesMedications: captopril, metformin, naproxenExam: unkempt, apathetic, R knee effusion
What further questions would you ask?
What would you look for in the physical exam?
Important points in the history
Anorexia?Early satiety?Nausea?Change in bowel habits?Fatigue or apathy?Memory loss?Depression?Food availability? Poverty?Social history
Physical signs of Undernutrition
Loss of subcutaneous fat- interossei and palmar creases- loss of fullness in arms, chest wall- squared-off appearance of shoulders
Muscle wasting (sarcopenia)- loss of tone and bulk in quadriceps, deltoids- reduced strength
Edema of ankles, sacrum, and even ascites- absence of weight loss misleading
Dysphoria, decreased cognitionPoor wound healing, pressure ulcers
Parameters Used in Identifying Undernutrition
Body weight loss (>5% in 30 days or 10% in 180 days)Body mass index < 19 kg/m2 (may be spuriously elevated)
Severe if BMI < 16Dietary food intake of less than 75% of meals for 3 daysSerum albumin value of less than 3.5 or 3.0 g/dl (decreases by 0.8 per decade after age 60) Influenced by
posture, CHF, dialysis, cytokines, dialysis, nephrosis, paraproteinemias
Serum cholesterol value of less than 160 mg/dl (occurs late, limited use for screening)
Associated with hospitalizations, LOS, complications, mortality
Screening and Assessments ToolsSCALES - outpatient screening toolDETERMINE - a low specificity tool, increases public awareness, and easily performed by the patient
- developed by the Nutrition Screening Initiative (AAFP, Am Diet.Assoc, Nat Council of the Aging)- Level I Screen separates those who need evaluation and intervention from those who need other medical and community services
- Level II Screen by physician or other primary provider (includes anthropometrics, labs, social and functional testing
MNA - Mini Nutritional Assessment. Malnutrition Inflammation Score (dialysis patients)
SCALES Protocol for evaluating risk of malnutrition in the elderly (scores > 3 indicates patient at clear risk) Morley 1991
Item evaluated Criterion for 1 point Criterion for 2 points
Sadness GDS 10-14 > 15
Cholesterol < 160 mg/dl --
Albumin 3.5 - 4.0 g/dl < 3.5 g/dl
Loss of weight (MAC 1 month)
1 kg (or ¼” in MAC in 6 months)
3 kg (or 1/2”)
Eating problems assistance
Patient needs --
Shopping and food prep problems
Patient needs assistance
--
Why does caloric intake decrease in the elderly?
ALTERATIONS IN THE HEDONIC QUALITIES OF FOOD WITH AGING
Food enjoyment depends on taste, odor, temperature, texture, masticatory sounds, all of which are alteredSmell declines progressively; hence monotonous diets
Alzheimer’s, Parkinsonism, laryngectomy, B12 deficiency, hypothyroidism, RF, cirrhosis, diltiazem, streptomycin
Reduction in sensory-specific satietyIncrease in taste thresholds; sweet least affected modality; flavor enhanced foods better consumedDifficulty recognizing taste mixturesSocial isolation
Anorexia of aging- Physiological reduction in food intake with advanced age
Food intake is lower in healthy older persons, especially of fat rather than carbohydrates
BMR due to loss of muscle
ImmobilityGreater satiation after a standard meal than younger peopleReduced fundic nitric oxide leads to a decrease in adaptive relaxation and earlier satiation ( by leptin, by NPY)
Opiod feeding drive (for fats) is less efficient Refeeding can reset appetite
Copyright ©2006 BMJ Publishing Group Ltd.
Hoffer, L J. BMJ 2006;333:1214-1215
Elderly demented patients often eat enough for their diminished energy requirements
Some postulatedfactors involved in the pathogenesis of physiologic anorexia
Taste and smell
CENTRAL NERVOUS SYSTEM
DynorphinNeuropeptide YCART
ANOREXIA
WEIGHT LOSS
CYTOKINESTNF αInterleukin-1Interleukin-6
STOMACHadaptive relaxn
Antral stretch
DUODENUMcholecysto-
kinin
OVARIESestrogen
ADIPOCYTESleptin
TESTIStestosterone
muscle mass
Neurotransmitters and Hormones Involved in the Control of Food Intake ( changes with aging)
Stimulate Inhibit
Peripheral motilinghrelin
CholecystokininGlucagon-like peptide 1
Amylin
Leptin (males only)cytokines
Hormones Thyroid CortisolTestosterone Progestagens
Estrogen (females only)
Central Dynorphin Dopamineneuropeptide Y Norepi
orexinA HistamineMelanin-conc H NO
CRHSerotoninIsatinDopamine
CART
Pathophysiology of protein-energy malnutrition.
Stress, InfectionBurns, Trauma
Inc macrophage proliferationInc release of IL1, TNFColony stim factorGamma interferon
Inc ESRLeukocytosisAnorexiaProtein catabolismWeight loss
Increase inGlucocorticoidsMineralocorticoidsADHDecreased IGF1
GluconeogenesisProtein catabolismLipolysisFluid, electrolyte shifts
Protein Energy MalnutritionHypoalbuminemiaLiver dysfunctionDecreased host defensesInc requirement for Cals + protein
“Meals on Wheels”: causes of weight loss
M: medications (dig, theophylline, fluoxetine)E: emotional (depression)A: alcohol, anorexia tardive, or elder abuseL: late life paranoiaS: swallowing problems (dysphagia, candidiasis, webs)
O: oral or dental problems (xerostomia)N: nosocomial infections (TB, C.Diff, H Pylori)
W: wandering, dementia problemsH: hyperthyroidism, hypercalcemia, hypoadrenalismE: enteric problems (gluten entropathy, pancreatic insufficiency)E: eating problemsL: low salt, low fat diets (ADA and other therapeutic diets)S: shopping and food preparation problems Morley
Causes of weight loss - MEDICALDysgeusia (antibiotics, captopril, tegretol, allopurinol, L dopa, lithium, baclofen, antihistamines, Vit A, zinc deficiency)Anorexia (Addison’s disease, dyspepsia*,H. Pylori infection, hypercalcemia)Oral and swallowing problems, dry mouth, poorly fitting dentures, web stricture, esophageal candidiasisMalabsorption (Celiac disease, intestinal ischemia)Increased metabolism (hyperthyroidism, pheochromocytoma)Metabolic (diabetes, hepatic, renal, cardiac failure)Chronic infections, TBMixed causes (cancer*, Parkinsonism, COPD, cardiac cachexia)
Causes of weight loss - SOCIALPoverty, fixed incomeFunctional impairment limiting ADL’S, dependancySocial IsolationElder abuse, caregiver fatiguePoor nutritional knowledgeFinicky eatersAlcoholInstitutional factors- inadequate assistanceEthnic food preferencesMonotony of institutionalized food
Causes of weight loss -PSYCHOLOGIC
DementiaDepression*BereavementAlcoholismLate-life mania or paranoiaAnorexia tardive or nervosaSociopathy (loss of locus of control)Excessive burden of lifePhobias (cholesterol or choking)Globus hystericus
Drug Therapy That May Contribute to Nutritional Disorders
Cardiac glycosides (digoxin)DiureticsAnti-inflammatory drugsAntacids (overuse)Psychotropic drugsAntidepressants (SSRI’s)Antineoplastic drugsAnticonvulsantsPhenothiazinesOral hypoglycemicsAnti-parkinsonianAnticholinergic
Alibhai, CMAJ. 2005 March
So What is Frailty?
A physiologic state of increase vulnerability to stressors that results from decreased physiologic reserves and even dysregulation, of multiple physiologic systemsEvidence indicates that Frailty may be a result of alterations in metabolic activity, that then leads to derangement of normal physiology
Cytokine over expressionHormonal imbalances
Frailty vs. Disability vs. Co morbidity
Fried, LP, et al. Journal of Gerontology 2001 M146 – M156
Consequences of FrailtyDisability
Difficulty with Activities of Daily living
Dependency
Falls
Need for Long – Term Care
Mortality
Phenotype of FrailtySHRINKING
Unintentional weight lossSarcopenia
WEAKNESSPOOR ENDURANCE & ENERGYSLOWNESSLOW ACTIVITY
Fried, LP, et al. Journal of Gerontology 2001 M146 – M156
FRAILTY: 3 or more criteria
PREFRAILTY: 1 or 2 criteria
Frailty Syndrome Criteria
WEAKNESSGrip strength in the lowest 20% at baseline; adjust for gender and BMIMEN Cutoff for Grip Strength
(Kg) criterion for frailtyBMI </= 24BMI 24.1 – 26BMI 26.1 – 28BMI > 28
<29<30<30<32
WOMEN Cutoff for Grip Strength (Kg) criterion for frailty
BMI </= 23BMI 23.1 – 26BMI 26.1 – 29BMI > 29
<17<17.3<18<21
Aging & Frailty
Revised schematic of homeostenosis: The older person employs or consumes physiologic reserves just to maintain homeostasis, and therefore there are fewer reserves available for meeting new challenges
Copyright © 2003 Spring-Verlag New York, Inc. All rights reserved.
Cycle of Frailty
Cytokine Over ExpressionIL-6, IL-1, TNF-a, IL-2, Hsp70
Sarcopenia
Osteoporosis or osteopenia
anemia
Cognitive decline
atherosclerosis
Impairments in Function, mobility, and/or endurance
PAD, CAD, Cerebrovascular disease
Dementia Fractures Falls
Falls, Heart failure…
FRAILTY
Cytokines & FrailtyInterleukin -6 (IL-6), TNF-alpha, Heat Shock protein 70:
Found to be elevated in older adults who complain of fatigue and found to have poor mobility and poor muscle endurance
Bautmans et al. JAGS. 56:3, pgs 389-396
IL-6 found to be elevated in older people with cachexia
Hubbard et al. JAGS. 56:2, pgs 279-284
That subclinical anemia may be a related to chronic inflammatory state marked by serum IL-6 elevation
Leng et al. JAGS. 50:7, pgs 1268-1271
Hormones & FrailtyHormone Deficient states may lead to the
following
Growth Hormone, IGF-1 Sarcopenia, Osteoporosis
Testosterone Cognitive decline, Depression, Osteoporosis
Estrogen * Osteoporosis, Cognitive decline
Vitamin D Osteoporosis, Sarcopenia, poor mobility
* Replacement not recommended
Prevention of Frailty
Address Nutrition, Function & Co-morbiditiesDiabetes ControlStroke preventionCAD, PAD treatmentFall prevention, Physical therapy interventionsExerciseNutritional evaluationsImmunizations, Vaccinations
F. R. A. I. L. T. Y.
Food intake: Maintain nutrition, protein intake, fiber intakeIn between meal supplementsAppetite enhancers such as marinol and megestrolSupplement for any nutritional deficiencies
B12, B6, Folate
F. R. A. I. L. T. Y.
Resistance exercise 3x/ weekResistance with weights or bands builds muscles and helps reduce joint stiffness and painExercise has been shown to
Increase muscle strengthIncrease muscle sizeIncrease gait velocityIncrease mobility
Case 2A 68 yr old retired accountant is noted to have a 12 lb weight loss at his clinic visit for a diabetic foot ulcer, complicated by chronic osteomyelitisMeal intake reduced by 50%, but he has adequate resources and lives with his wife who is his caregiver. More fatigued and slow.Exam: CBG 209, cheerful, sarcopenia in UE and LE, draining heel wound,
How would you manage this patients weight loss?
Treatment StrategiesIdentify cause/causes and initiate targeted dental, medical, psychological, social, or community interventionThorough evaluation of all prescription and OTC medicationsNutrition counseling of patient and caregiversNutritional supplementationIncreased staff at mealtimes, food presentation, taste enhancement, change meal times (not 8-5 PM)Orexigenic drugs
Useful non-invasive screening testsComplete blood countLiver function tests (including alkaline phosphatase and bilirubin), measurement of LDHChest radiographyPatients with iron-deficiency anemia or symptoms likely to originate in the gastrointestinal tract, and patients with elevated liver enzyme levels on initial screening, should undergo
either endoscopy or UGI series or abdominal ultrasound
A rational approach to the treatment of weight loss in the elderly.
Identify and treatthe cause
No cause identified orno treatable condition
Improved prognosis+ quality of life
Weight gainDespite therapy no increase in weight
NUTRITIONAL SUPPORTFrequent small meals high inprotein and fatSupplements, night snacksPHYSICAL THERAPY
ExerciseOCCUPATIONAL THERAPY? ANABOLIC AGENTS
No weight gain
Poor prognosis
Consider enteralHyperalimentationNo terminal illlnessPt + family consent
Algorithm for managing weight loss in outpatientsDEHYDRATION? YES Treat
DECREASED FOOD AVAILABILITY?YES Refer to social
workerAPPETITE PROBLEM?
YES NO
MALABSORPTION?YES
TreatDELIRIUM?YES
Treat
NO
DEPRESSION?YES
Treat
NO
CONSIDER OREXIGENICS
NO
HYPERMETABOLISM?
YES
TreatLOOK FOR TREATABLE CAUSES? Malignancy ?other
NO
NO
Nutritional supplementation Palatable meals high in protein and fatsGive priority to ethnic food preferences Nutritional supplements as meal replacements or late night snacksLiquid energy supplements to swallow medications (Medpass 2.0 can treat weight loss in nursing homes)Begin aggressive efforts to assure adequate intake 48h after acute hospital admissionEnteral tube feeding (NG or J tube) has fewer problems, is more cost-effective and efficient than parenteral feeding (TPN)Peripheral parenteral nutrition (PPN) for short term support (10% dextrose, amino acids and intralipid)
Calculating enteral feeding requirements
Clinical condition Amount
Protein* Maintenance 1.2 – 1.5 g/kg/day
Stress* 1.5 – 2.0 g/kg/day
Calories# Maintenance 25 – 30 kcal/kg/day
Stress 30 – 40 kcal/kg/day
Sepsis 40 – 50 kcal/kg/day
Free water 30 – 35 ml/kg/day*Use IBW in obese persons# Use 120% IBW in obese persons
Pharmacological treatment of weight loss
Small gain in weight without evidence of decreased morbidity and mortality or improved function and quality of lifeOrexigenic (appetite-stimulating) and anabolic medications Only 4 have been studied in randomized trials
Orexigenic Drugs
AGENT MECHANISM OF ACTION
Megestrol acetate Progestagen/anticytokineDronabinol CannabinoidCyproheptadine AntiserotoninAnabolic steroids (Oxandrolone) Mainly on muscleGrowth Hormone CentralCorticosteroids CentralMetoclopromide Increased gastric emptyingAntidepressants Treat depression(Mirtizapine) 5HT1 agonist, 5HT2 antagonist
MEGESTEROL ACETATEProgestational effect antagonizes estrogen (which ↓ food intake)Main effect is antagonism of cytokine production (TNFα, IL6)Increases appetite, weight, well being and fat massUseful in older persons with anorexia caused by cytokine excess (cancer, AIDS, P ulcers, arthritis, recurrent infections)May cause DVT or adrenal suppression
Orexigenic drugs and Their Side Effects
Cyproheptadine DeliriumTestosterone (gel,patch, Increased Hct
injection) Not with prostate CaFluid retentionSkin irritation
Oxymethalone/oxandrolone Liver dysfunctionnandrolone Renal failure
Growth hormone Carpal tunnel syndromeArthralgiasIncreased death
Megestrol acetate Deep vein thrombosishypoadrenalism
Dronabinol Delirium
Morley. Clin Geriatr Med Nov 2002
Addressing Weight Loss Issues
in the Elderly
Voluntary Weight LossDietary modification required because of OW/OBWeight modification because of diagnosed medical conditionsPersonal feelings of OW
Involuntary Weight LossDepression (> in LTCF)CancerCardiac disorderAlcoholism Benign gastrointestinal diseasesMedicationPolypharmacyCognitive impairment
Nutrition Assessment is Key
Physiologic Anorexia of Aging
By the age of 65 years, approximately 50 percent of Americans have lost teeth!
Weight loss should NEVER be considered as part of
the normal aging process.
Nutritional AssessmentAnthropometric measuresGeneral physical assessmentDietary assessmentSelf assessmentMedication reviewEnvironmental scan
TreatmentTeam approachUse of flavor enhancersSmall, frequent mealsExerciseMedicationsFeeding tubes
Voluntary Weight Loss IssuesPlanningExercise↓ fat usually preferredSmall, frequent meals/snacks
!!! REMEMBER !!!
Eating food is one of life’s greatest pleasures as we mature!
QUESTIONS?Naushira Pandya, MD, CMD [email protected] Rokusek, EdD, [email protected]