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Older Adult Exam 1 > Nutrition > Flashcards

Nutrition Flashcards

1
Q

What is clinically important involuntary weight loss?

A

5% weight loss over a one year period
>10 pounds in six months
>5% in 30 days
10% in 180 days

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2
Q

What subsets of the elderly are most impacted by involuntary weight loss?

A
  • Patients with dementia, especially those that are institutionalized (50% vs. 30% non)
  • Frail elderly
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3
Q

What are some effects of involuntary weight loss in the elderly?

A
  • Increased frailty and mortality
  • Increased hospital admissions and increased risk of in-hospital complications
  • Increased falls and injuries from falls
  • Impaired cell-mediated and humoral response with increased rate of infections
  • Loss of lean body mass with impaired skeletal muscle, cardiac muscle, and respiratory function
  • Delayed wound healing
  • Decreased functional ability and ADLs
  • Higher rates of admission to an institution
  • Poorer quality of life
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4
Q

What are some approaches to dealing with reversible weight loss?

A
  • assessment
  • diagnosis
  • treatment
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5
Q

What are some problems associated with trying to treat irreversible weight loss? What are some examples of irreversible weight loss?

A

Trying to treat irreversible weight loss can be…

  • frustrating
  • painful
  • emotionally draining
  • expensive
  • fruitless
  • examples: dementia, cancer
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6
Q

What are some causes of weight loss in older adults?

A
  • Physiological
  • Medical
  • Functional
  • Psychological
  • Social
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7
Q

What are some physiological factors that contribute to anorexia in aging, particularly thinking about chemosensory changes?

A

Diminished sensory-specific satiety

Change in taste and smell

  • Increased threshold for salt other specific tastes
  • Decreased taste sensitivity due to decreased taste receptor turnover (number of taste buds does not change)
  • Medications that alter senses of taste and smell
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8
Q

What are some physiological factors that contribute to anorexia in aging, particularly thinking about GI factors?

A

Delayed gastric emptying

  • Prolonged antral distention
  • Increased absorption time
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9
Q

What are some physiological factors that contribute to anorexia in aging, particularly thinking about gut hormones?

A
  • Elevated levels of glucagon (GLP-1), CCK, and leptin (increase satiety, decrease hunger, decrease food intake)
  • Decreased levels of ghrelin (growth hormone produced by the stomach that increases appetite and food intake)
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10
Q

What are some medical clauses of involuntary weight loss?

A
  • Malignancy
  • Infectious (bacterial, TB, fungal, parasitic)
  • Inflammation (autoimmune diseases like rheumatoid arthritis)
  • Endocrine (DM, hypo/hyperthyroid, adrenal insufficiency)
  • Organ failure (CHF, chronic renal insufficiency, COPD)
  • Medication side effects
  • Deficiencies (B12, folate, iron, thiamine, Vitamin C, zinc)
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11
Q

What are some medication side effects that can contribute to weight loss?

A
  • Anorexia
  • Dry mouth
  • Dysgeusia/dysosmia
  • Nausea/vomiting
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12
Q

What are some types of medications that can cause anorexia?

A
  • Antibiotics
  • Anticonvulsants
  • Metformin
  • SSRIs
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13
Q

What are some types of medications that can cause dry mouth?

A
  • Anticholinergics
  • Antihistamines
  • Diuretics
  • Clonidine
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14
Q

What are some types of medications that can cause dysgeusia/dysosmia?

A
  • ACEIs
  • Antibiotics
  • Anticholinergics
  • CCBs
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15
Q

What are some types of medications that can cause nausea/vomiting?

A
  • Antibiotics
  • Digoxin
  • Hormone replacement
  • Iron
  • Potassium
  • SSRIs
  • Statins
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16
Q

What are some functional causes of involuntary weight loss?

A
  • Immobility
  • Arthritis
  • Stroke
  • Parkinson’s disease
  • Dental problems
  • Visual loss
  • Hearing deficits
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17
Q

What are some psychiatric/psychological causes of involuntary weight loss?

A
  • Depression
  • Psychosis
  • Grief/bereavement
  • Intentional
  • Alcoholism
  • Dementia
  • Anorexia nervosa/anorexia tardive
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18
Q

What are some social causes of involuntary weight loss?

A
  • Poverty
  • Isolation
  • Neglect
  • Abuse
  • Caregiver fatigue
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19
Q

How do we evaluate a person’s weight loss?

A
  • Weigh the patient
  • Calculate BMI (undernutrition < 22)
  • Careful H&P with emphasis in pharmacologic and psychosocial factors
  • Lab studies
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20
Q

What are some basic screening tests that we should collect on a patient with suspected involuntary weight loss?

A
  • UA
  • CBC,
  • Electrolytes
  • LFTs
  • TFTs
  • Renal function
  • Stool occult blood
  • CXR
    Consider upper and lower endoscopies
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21
Q

What are some diagnostic indicators of poor nutrition?

A
  • Albumin < 3.4 g/dL
  • Cholesterol < 160 mg/dL
  • Transferrin < 180
  • Hgb < 12 g/dL
  • Triceps skin fold thickness
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22
Q

What is a validated screening tool you can use to assess for malnutrition in your patients?

A

Mini nutritional assessment- short form

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23
Q

What are some nonpharmacologic treatments for involuntary weight loss?

A
  • Minimize dietary restrictions
  • Optimize energy intake (high energy foods at the best meal of the day, smaller meals more often “eat with the clock, not your appetite,” favorite foods and snacks)
  • Optimize and vary dietary texture
  • Avoid gas producing foods
  • Ensure adequate oral hygiene and health
  • Take nutritionally dense supplements
  • Eat in company or with assistance, hand-feed the patient
  • Use lever enhancers, maximize taste and smell
  • Participate in regular exercise
  • Take a multiple vitamin supplements daily
  • Use community nutritional support services, like Meals on Wheels
  • Minimize aspiration risk by eating appropriate diet as evaluated by SLP
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24
Q

How does energy intake needs change with age?

A
  • Energy intake needs declines significantly with aging due to reduction in basal energy expenditure and decline in physical activity
  • Goal: 25 kcal/kg/day
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25
Q

What are the macros needed for older adults?

A
  • Protein intake: 0.8-1.2 g/kg/day (higher in patients with pressure ulcers)
  • Carb intake: minimum of 130 g/day, 50% complex, 20-30g fiber
  • Fat intake: < 30% of total calories; < 10% saturated fat
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26
Q

How should older adults consume micronutrients so that they are receiving adequate amounts?

A
  • Prefer dietary consumption of micronutrients over supplements
  • May recommend a multi-vitamin on top of a nutritionally balanced diet
  • May recommend other specific supplements based on lab work
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27
Q

What are some water soluble vitamins that are commonly deficient in the elderly?

A

Folate, RDA 400 ug/day

  • No evidence of increased requirement in the elderly
  • Low levels more common in elderly alcoholics (poor intake and decreased absorption)
  • Over supplementation (> 1 mg) may mask vitamin B12 deficiency

Cyanocobalamine (B12), RDA 2.4 ug/day in adults > 51yo
- 10 to 15% elderly have the B12 deficiency from reasons like achlorhydria, antacid use, H. pylori infection, etc.

Thiamine (B1), mandatory enrichment of food ensures that the RDA is met
- Low levels most common in elderly alcoholics (from poor intake and decreased absorption)

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28
Q

What are some fat soluble vitamins that we should watch in the elderly? What is the risk of supplementation of some of these vitamins?

A

Vitamin A, RDA 700 RE in women and 900 in men

  • Requirement does not increase with age
  • Clearance is reduced
  • Risk for hypervitaminosis: significant toxicity with chronic ingestion (SE: Headaches, leukopenia, hypercalcemia)

Vitamin D, RDA > 70, 600-800 IU
- Requirement increases with age due to reduced skin photosynthesis, reduced sun exposure, reduced absorption, reduced 1 hydroxylation of 25(OH)D

Vitamin E

  • Deficiency is limited to cases of severe, long-standing fat malabsorption
  • Amount in diet is usually adequate
29
Q

What is the forgotten nutrient, and what are the needs of this nutrient in the elderly?

A

Water!

  • Decreased thirst response
  • Reduced concentration capacity by the kidneys
  • Water needs: 1 mL/kcal or 30 mL/kg of body weight
30
Q

What have studies concluded about protein and energy supplementation?

A
  • supplementation appears to produce small but consistent weight gain
  • statistically significant beneficial effect on mortality and a shorter length of hospital stay
31
Q

What are some examples of oral supplements we can suggest to patients and what is each one’s use?

A
  • boost plus: high cal, high protein
  • carnation: very high cal, high protein
  • resource diabetic: diabetic, high protein
  • enlive: clear liquid supplement
  • nubasics fruit beverage: clear liquid supplement
  • gatorade: clear liquid supplement
  • ensure pudding: consistency modified
  • benefiber: fiber supplement
  • procel: modular protein
  • thicken-up: powder thickener
32
Q

When should we consider consulting the nutritionist?

A
  • enteral/parenteral support
  • unintentional weight loss >5%
  • n/v/d > 5 days
  • poor oral intake, < 50% of meals > 3 days
  • difficulties chewing, swallowing, aspiration precaution diet
  • NPO > 3 days
  • albumin < 3.4
  • wound/pressure ulcer (any stage)
  • transplant patients
  • newly diagnosed of uncontrolled diabetic/CHF/ESRD
33
Q

What are some pharmacological treatments for those with involuntary weight loss?

A

appetitie stimulants = orexigenig agents

  • megestrol acetate
  • dronabinol
  • anabolic agents
  • antidepressants
  • gastroprokinetic agents
  • other experimental drugs
34
Q

what kind of med is megase and how does megestrol acetate help stop involuntary weight loss?

A
  • progestational agent that produces an increase in food intake
  • many studies show increase in weight gain, but some show only fat gain and not gain in lean body mass
  • many studies show improvement in sense of well being =
35
Q

what is the MOA of megase?

A

unclear

  • alteration of CNS neurotransmitters involved in regulation of food intake
  • antagonizes cytokine production (potent anorectic agents)
36
Q

what is the typical dose and length of treatment needed for megase to be effective?

A
  • doses range from 80-800 mg/day suspension

- studies show that the med needs to be provided longer than 12 weeks

37
Q

what are common side effects of megestrol acetate?

A
  • thromboembolism
  • fluid retention
  • flushing
  • erectile dysfunction
  • vaginal bleeding
  • adrenal insufficiency
  • diabetes
  • decrease in testosterone levels
38
Q

to which types of patients should we avoid giving megase?

A

bed-bound patients bc of increase in incidence of DVTs

39
Q

what treatment is recommended for those on megase with urgent surgery or has an infection during treatment course longer than 8-12 weeks?

A

stress dose of steroids

40
Q

how does dronabinol help those with involuntary weight loss?

A
  • cannabis was used as an appetite stimulant in ancient Arabic medicine
  • increases desire for food, improves taste, makes substances smell richer, decreases pain, and improves mood
  • effective appetite stimulant for AIDS and cancer patient; antiemetic
41
Q

what is the dosage for dronabinol?

A

2.5-20 mg/day (5-7.5 mg at HS for older demented patients)

42
Q

what are the major side effects of dronabinol?

A
  • delirium
  • abdominal pain
  • nausea
  • ataxia
43
Q

what are some anabolic agents used to prevent involuntary weight loss?

A
  • testosterone
  • anabolic steroids
  • growth hormone and IGF-1
  • glucocorticoids
44
Q

how does testosterone help prevent involuntary weight loss?

A

increases muscle mass, decreases fat mass, and increases bone mineral density

45
Q

what are the side effects of testosterone?

A

hct > 54%, leg edema, exacerbation of prostate cancer

46
Q

what are the anabolic steroids used to prevent involuntary weight loss?

A
  • oxandrolone and nandrolone

- improved weight

47
Q

what are the side effects of anabolic steroids?

A
  • liver toxicity
  • fluid retention
  • renal failure
48
Q

what types of patients benefit from use of growth hormone and IGF-1? how do these prevent involuntary weight loss?

A
  • severely ill, malnourished patients

- nitrogen retention and weight gain

49
Q

what are the side effects of growth hormone and IGF-1?

A
  • glucose intolerance/insulin resistance
  • peripheral edema
  • gynecomastia
50
Q

what types of patients benefit from use of glucocorticoids? how do they prevent involuntary weight loss?

A
  • hospice patients

- improve appetite and mood

51
Q

limitations of glucocorticoids in regardings to helping involuntary weight loss?

A

have minimal impact of weight gain or function

52
Q

what is the most common, treatable cause of anorexia and weight loss?

A

depression

53
Q

what is the best antidepressant for helping with involuntary weight loss in older adults?

A

mirtazapine

54
Q

what is the MOA of mirtazapine? how does it help with anorexia?

A
  • enhances norandrenergic and serotoninergic neurotransmission
  • this combo enhances appetite
  • improved appetite and weight gain over SSRIs
55
Q

what are some of the causes of eating problems in advanced dementia?

A
  • oral dysphagia: absent or continuous chewing with tendency to pocket or spit food
  • pharyngeal dysphagia: delayed swallowing initiation, multiple swallows, and aspiration
  • loss of ability to perform task of eating
  • loss of ability to interpret the sensation of hunger
  • disinterest in food due to depression
  • refusal to eat
56
Q

what are the indications for placing a PEG tube according to the American Gastroenterological Association (AGA)?

A
  • prolonged tube feeding (> 30 days)
  • patient cannot/will not eat
  • gut is functional
  • patient can tolerate the placement of the device
57
Q

what is the second leading indication for upper GI endoscopy?

A

PEG placement

58
Q

what are some patient characteristics associated with a high likelihood of being tube fed?

A
  • younger age
  • nonwhite race
  • lack of advanced directives
59
Q

what does PEG stand for?

A

percutaneous endoscopic gastrostomy

60
Q

what are some major complications of PEG placement?

A
  • aspirations PNA
  • peritonitis
  • hemorrhage: puncture of gastric wall vessel
  • buried bumper syndrome: migration of tube into the gastric wall and epithelialization of the ulcer site
  • gastrocolocutaneous fistula
  • wound infection
  • necrotizing fasciitis
  • inadvertent removal of PEB tube
61
Q

what are some minor complications of PEG placement?

A
  • tube leakage

- tube blockage

62
Q

what are some of the goals that providers and caregivers are trying to achieve by placing a PEG in someone with dementia?

A
  • provide nutrition and hydration
  • reduce risk of aspiration PNA
  • improve pressure ulcers
  • improving nutrition parameters
  • improve survival
  • (facilitate transfer to LTC facilities)
  • (increase caregiver convenience)
  • (comply with LTC facilities’ policies)
63
Q

what are some assumptions that people make about what a PEG tube will accomplish? are these things true?

A
  • provide adequate nutrition
  • prolong patient’s life
  • eliminate suffering
  • prevent aspiration PNA
  • improve skin integrity by increasing protein intake (this is the only correct answer)
  • improve functional status and/or quality of life
64
Q

does a PEG prolong life?

A
  • data doesn’t show survival advantage
65
Q

does a PEG eliminate or cause suffering and why?

A

causes suffering 2/2

  • surgical/wound issues: infection, bleeding, leakage, abscess, peritonitis
  • increased use of restraints and subsequent pressure sores
  • need for pharmacological sedation
  • electrolyte disturbance
  • aspiration PNA after placement
  • increased urine and stool production, diarrhea or constipation, vomiting
  • decreased contact with caregivers
  • deprivation of the joy of eating
  • increased number of transfers to acute care facilities due to tube dislodgement or leakage
66
Q

do PEG tubes prevent aspiration PNA?

A

they are a risk factor of aspiration PNA and GERD

67
Q

why do people still use PEG tubs in people with advanced dementia?

A
  • economic incentives/NH issues
  • path of less resistance
  • state law
  • family concerns over starving
  • religious beliefs
  • lack of understand of terminal nature of advanced dementia
  • physician’s beliefs
68
Q

what are some alternatives to PEG tubes?

A
  • hand feeding
  • easy-to-swallow high energy foods
  • elimination of sedating medications
  • improvement of dental hygiene
  • swallowing cues

Older Adult Exam 1 (7 decks)

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