Nutrition Interventions in the anorexic Geriatric Patient

1. Nutrition Interventions in the anorexic Geriatric Patient By: Nicole Greene

2. Agenda • Defining Geriatrics • Physiologic Changes of Aging • Psychological Changes with Aging • Medical Nutrition Therapy of the Malnourished Geriatric Patient • Presentation of M.C. • Critical Comments • Summary • Questions • References

3. Introduction • Aging can’t be prevented • Malnutrition In the elderly often overlooked • How does physiologic, mental, and psychological changes affect nutrition in the elderly population? • How can an early nutrition intervention improve quality of life?

4. Defining Geriatrics • Greek origin • Geron– elder • Iatros- healer • Sub-specialty of internal and family medicine focused on prevention and treatment of diseases and disabilities in the elderly • Many countries have accepted the age of 65 as the definition of “elderly”

5. Geriatric population

6. Physiologic Changes associated with Aging • Different than treating a mid aged adult • Problems arise from choices made in their history • Changes can be summarized into several categories relating to the organ systems they compromise • Every patient unique and may be experiencing different problems

7. Bone, Muscle, and Joint Issues in the Elderly

8. Cardiovascular conditions in Geriatric patients • Atrial Fibrillation • Hypertension • Coronary Artery Disease • Myocardial Infarction • Congestive Heart Failure • Valvular Disease

9. Respiratory conditions in the elderly • Decreased elastin • Decreased vital capacity • Decrease # of alveoli • Decrease # of celia

10. GI Symptoms in the elderly • Decrease in saliva production • Esophageal dysfunction • Atrophic gastritis • Achlorhydria • Decreased liver metabolism • Decreased absorption-lactose, calcium, iron

11. Changes in the elderly’s urinary system • Vascular blood flow to the kidneys decreases • Nephrons decrease • Decreased tissue mass • Bladder wall become less elastic

12. Changes in the Elderly’s Nervous System • Central processing of eye is decreased • Hearing losses • Slowing down of thought and memory • DEMENTIA IS NOT A NORMAL PROCESS OF AGING

13. Changes in the Elderly’s Immune System

14. Psychological aspects of aging • Psychological, biological, environmental, and genetic factors all contribute to depression • Depression last longer in the elderly and increases the risk of death from illness

15. Malnutrition • Malnutrition Increased morbidity and mortality in elderly • Lack of protein, energy, and other nutrients causes adverse effects on tissue form, composition, function, or clinical outcome • The ADA/A.S.P.E.N. has developed criteria to diagnose malnutrition in adults • Serum proteins such as albumin and prealbumin are not included as defining characteristics of malnutrition

16. Diagnostic Tool to identify malnutrition

17. Causes of Malnutrition in The geriatric population • Poor appetite • Chronic illness • Multiple medications • Cognitive decline • Physiologic weakness • Oral health • Dysphagia • Diarrhea or constipation • Economic hardship

18. Consequences of malnutrition • Morbidity and mortality • Greater risk for infections • Cachexia • Failure to thrive • Delayed wound healing • Impaired respiratory function • Muscle weakness • Depression

19. Assessing the Malnourished Geriatric Patient • Physical signs • Muscle wasting • Temporal wasting • Poor skin integrity • Delayed healing • Subcutaneous fat loss • Hair loss

20. Assessing the Malnourished Geriatric Patient • Body Mass Index

21. Assessing the Malnourished Geriatric Patient • Interpretation of % Weight Change

22. Assessing the Malnourished Geriatric Patient • FAILURE TO THRIVE • Syndrome manifested by weight loss greater than 5 percent of baseline, decreased appetite, poor nutrition, and inactivity • Four syndromes are prevalent and predictive of adverse outcomes in patients with FTT: • Impaired physical function • Malnutrition • Depression • Cognitive impairment

23. Clinical Manifestations of Refeeding syndrome

24. Estimating Nutritional Needs in the malnourished geriatric Patient • Caloric Needs • Weight based calculations  use actual weight for normal and underweight individuals

25. Estimating Nutritional Needs in the malnourished geriatric Patient • Caloric Needs • The Academy suggests a dietary prescription of 130% of the REE, but should be avoided when the patient is at risk for refeeding syndrome • Penn State equation or Ireton Jones for critically ill

26. Estimating Nutritional Needs in the malnourished geriatric Patient Protein Needs: *Wounds and different disease states also may increase or decrease protein needs

27. Estimating Nutritional Needs for Refeeding syndrome • Start low and go slow • Protein should not exceed 1-1.5 gm/kg of normal weight in the early stages of refeeding • Calories: 20-25 kcal/kg actual body weight • If feeding Parenterally: CHO load start with 2 mg/kg/minute- prevents gluconeogenesis and minimizes insulin secretion • Restrict fluids to avoid edema • MONITOR LABS: ESPECIALLY PHOSPHORUS, POTASSIUM, AND MAGNESIUM

28. Methods of feeding the malnourished geriatric patient • Oral Feeding • Liberalizing the diet • Add High Calorie/High protein supplements • Enteral Nutrition • Can’t be fed orally or can’t meet needs orally • Parenteral Nutrition • Should only be initiated when medically necessary

29. Other Interventions • Possible medication changes • Remeron • Appetite stimulants

30. Evaluating Feeding Success in the Malnourished Geriatric Patient • Weight gain (not in fluid) • Healing wounds • Nitrogen balance • A positive nitrogen balance suggest that nutrition intake is adequate to promote anabolism and preserve lean muscle mass • Negative nitrogen balance is when nitrogen excretion exceeds intake, reflecting muscle deterioration

31. Presentation of Patient: MC • 68-year-old widowed Caucasian female • Transferred from Lions Gate Nursing Home for SOB and tachycardia • The patient apparently was not eating at all and is eating less than 5% of her diet report from Lions Gate Nursing Home • Weight is only 55 pounds • The patient was admitted here for psych evaluation for commitment and inpatient treatment

32. Initial Nutrition assessment (4/18/12) • Physician and RN consult, Calorie Count Consult • Diagnosis: • COPD • Anorexia • Tachycardia • Hx: • COPD • FTT • Cachexia • Kyphoscoliosis • Osteoporosis • Hypokalemia • Depression • Gait Instability

33. Food/Nutrition History • Transferred from Lyons Gate Nursing home • AAOx3 • PO ~5% per nursing records • Per H&P: Pt. refuses to eat, hides food, and throws up after meals • Calorie count initiated today • Pt. likes ensure and needs soft food • Noted poor intake x 7 years since husbands death (weight was 126#) • Per noted record: weight stable at 75# in July 2011 • ? At risk for refeeding Current Diet Order: Does not meet needs: pt. needs soft General Diet +Ensure TID+ Ensure pudding BID, RN to watch pt. eat meals

34. Labs:

35. Medications

36. Anthropometrics: -Multiple Stage I and II Pressure Ulcers- Wound care pending -Temporal Wasting -Poor Dentition -Hair Loss Physical Exam findings:

37. Nutritional Needs • Calories • 625 kcal will increase needs once clear from refeeding • Based on 25 kg weight • 25 kcal/kg • Protein • 34-51 g • Based on 34 kg (UBW) • 1-1.5 g/kg • Fluid • ~1290 ml • Based on 43 kg (IBW) • 30ml/kg

38. Nutritional Diagnosis • Suboptimal oral food beverage intake related to disordered eating as evidenced by weight loss of 26% over 8 months (severe), anorexia secondary to depression, BMI: 10.7, 57% of IBW • Goal: PO intake >50% of each meal/supplements within 3 days (calorie count)

39. Monitoring and Evaluation: • High acuity • Weight • PO intake/ kcal count • Electrolytes (Na, K, Mg, PO4) • Skin/Wound Care-pending • Psych Consult- pending • Increased needs

40. Nutrition Interventions • Nutrition Education: • Verbal needs for tolerating PO/Increased needs • Coordination of Other Care During Nutrition Care: • RN, Physician, and Calorie Count at Bedside • Recommend: • Check CRP, Folate, B12, Vit. D • Start MVI daily • Change diet to mechanical soft with ground meats • Pt. would benefit from PEG tube/encourage feeding tube and consider GI consult for placement • Monitor Electrolytes- may be at risk for refeeding • Consider 1:1 for questionable purging

41. Calorie Count Note (4/19/12) • PO intake poor secondary to eating disorder • Pt. PO 250 kcal, 7 gm protein • Minimal PO at breakfast and no PO at dinner • Pt. reports no appetite, but may be agreeable to PEG • Pt. complains of early satiety • Recommendations: As able, GI to F/U with pt. referring increased anxiety with PEG procedure

42. Update! (4/19/12) • Spoke with patient now agreeable for PEG • Consulted GI • Will await pulmonary clearance • Recommend: Once PEG placed, initiate Jevity 1.2 @ 20 ml/hr and increase by 10 ml q 4 hr until at goal rate of 40 ml/hr x 12 hr • 480 ml total volume • 576 kcal • 27 g Pro • 687 ml total H20

43. Nutrition Follow up (4/21/12) • A • Pt. ordered clear liquid diet • Calorie count range: 200-500 kcal/day • POD #1 S/P PEG placed • Jevity 1.2 @ 10ml @present (goal is 40 ml x 12hr/day with AF) • Pt. AAOx3 in good spirits • POC: rehab@ D/C • Once PEG feeds tolerated at goal 40mlx12 hr (576 kcal, 27 gm pro, 687 ml H2O), will progress or change feeds to bolus. No new lab data

44. Nutrition Follow up Continued (4/21/12) • D • Suboptimal EN related to goal not yet reached as evidenced by EN @ 10 ml/hr (goal is 40 ml/hr x 12 hr) • Goal: EN to meet estimated needs within 48 hours/ PO feeds for supplemental • I • Closely monitor electrolytes • Progress PO diet to mechanical soft with ensure BID • Oral care/ HOB • Jevity 1.2 @ goal 40 ml/hr x 12 hr/day with AF

45. Nutrition Follow up Continued (4/21/12) • M/E: High Acuity • PO intake • Electrolytes • EN tolerance • S/S of aspiration • Wound Healing

46. Nutrition Follow Up (4/24/12) • A: • Diet: mechanical soft general diet+ ensure TID+ ensure pudding BID • Jevity 1.2 @ goal rate of 40 ml/hr x12 hr via PEG • Oral PO 0% per RN flow and pt. report • EN feeds well tolerated • Would benefit from increased needs with stable electrolytes

47. Nutrition Follow up Continued (4/24/12) • Estimated needs: • 875-1000 kcal • 35-40 kcal/kg • Based on 25 kg weight • 66-88 g pro • 1.5-2.0 g pro • Based on IBW • 1275 ml H2O • Based on IBW • ~30 ml/kg

48. Nutrition Follow up Continued (4/24/12) • Additional Medications • Milk of Magnesia • Senokot • Zofran • Labs 132 L 93 L 12 67 L <0.30 L 3.5 33 H

49. Nutrition Follow up Continued (4/24/12) • D: • Increased nutrient needs related to protein/energy malnutrition as evidenced by muscle wasting and temporal wasting • Goal: pt. will meet estimated needs within 24 hours • I: • Jevity 1.2 @ 60 ml/hr x 12 hr (7pm-7am) + 2 oz liquid protein via PEG • Provides: • 720 ml total volume • 864 kcal + 120 (liquid pro) = 984 kcal • 40 gm pro + 30 gm (liquid pro) = 70 gm pro • Free H2O with AF: 806 ml

50. Nutrition Follow up Continued (4/24/12) • M/E: • Weight • Electrolytes, prealbumin • EN tolerance • Skin/Wound Healing • Increased needs with weight gain