Malnutrition & the older patient

James T. Birch, Jr., MD, MSPH Assistant Clinical Professor Dept. of Family Medicine Division of Geriatric Medicine Landon Center on Aging KU Medical Center February 19, 2007

Objectives
Outline the ACOVE indicators for malnutrition for community-dwelling and hospitalized older persons Understand the physiologic changes that contribute to the problem Identify the risks of malnutrition in the elderly patient Discuss nutritional screening and assessment tools

Objectives
Review basic nutritional requirements for the older patient Discuss options for nutritional intervention Review the ethical considerations for replacement of nutrition and hydration of the older patient Identify nutritional syndromes

Definition

Malnutrition is the condition that develops when the body does not get the right amount of vitamins, minerals, and other nutrients it needs to maintain healthy tissues and organ function. The condition may result from an inadequate or unbalanced diet, digestive difficulties, absorption problems, or other medical conditions. However, there is no universally accepted clinical definition.

Malnutrition is not something observed only in third-world countries. 1 Older persons suffer a burden of malnutrition that spans the spectrum from under- to overnutrition. 2
Malnutrition in the elderly is one of the greatest threats to

health, well-being, and autonomy.

1. Kiseljak-Vassiliades, K., et al. Basic Nutrition for Successful Aging: Part 1. Clinical Geriatrics, Vol. 14(4); April 2006 2. Geriatrics Review Syllabus: A Core Curriculum in Geriatric Medicine, Sixth Edition (GRS6); American Geriatrics Society 2006 3. Francesco, VD, et al. The Anorexia of Aging. Digestive Diseases 25(2); 2007

ACOVE - 3 Quality indicators for Malnutrition

ACOVE-3 indicators are comprised of IF-THENBECAUSE statements Apply to community-dwelling AND hospitalized older persons 8 quality indicators covering 4 domains Indicators are not supported by RCTs (except one) because most all studies have been small and involved persons who met narrow entry criteria or which lacked the highest quality of methodological rigor. Indicators are a product of literature review and expert panel consideration.

ACOVE-3 quality indicators

Indicator #1: ALL community-dwelling pts. Should be weighed at each physician office visit and these weights should be documented in the medical record BECAUSE this is an inexpensive method to screen for energy undernutrition and obesity that has prognostic importance.

ACOVE-3 quality indicators

Indicator #2: IF a vulnerable elder has involuntary wt. loss of > 10% of body wt. over one year or less, THEN wt. loss (or a related disorder) should be documented in the medical record as an indication that the physician recognized malnutrition as a potential problem BECAUSE some patients with wt. loss have potentially reversible disorders.

ACOVE-3 quality indicators

Indicator #3: IF a community-dwelling vulnerable elder has documented involuntary wt. loss or hypoalbuminemia (< 3.5g/dL), THEN she or he should receive an evaluation for potentially reversible causes of poor nutritional intake BECAUSE there are many treatable contributors to malnutrition.

ACOVE-3 quality indicators

Indicator #4: IF a community-dwelling vulnerable elder has documented involuntary wt. loss or hypoalbuminemia (< 3.5g/dL), THEN he or she should receive an evaluation for potentially relevant comorbid conditions including: Medications that might be associated with decreased appetite (digoxin, fluoxetine, anticholinergics), depressive symptoms, and cognitive impairment BECAUSE each of these represents a treatable contributor to malnutrition.

ACOVE-3 quality indicators

Indicator #5: IF a vulnerable elder is hospitalized, THEN his or her nutritional status should be documented during the hospitalization by evaluation of oral intake or serum biochemical testing (e.g., albumin, prealbumin, or cholesterol) BECAUSE each of these measures has prognostic significance and can identify older persons at risk of malnutrition or adverse outcomes (complications, prolonged length of stay, in-hospital and up to one-year mortality).

ACOVE-3 quality indicators

Indicator #6: IF a hospitalized vulnerable elder is unable to take foods orally for more than 72 hours, THEN alternative alimentation (either enteral or parenteral) should be offered BECAUSE such patients are at high risk of malnutrition that can improve with caloric supplementation

ACOVE-3 quality indicators

Indicator #7: IF a vulnerable elder who was hospitalized for a hip fracture has evidence of nutritional deficiency (thin body habitus or low serum albumin or prealbumin), THEN oral or enteral nutritional proteinenergy supplementation should be initiated post-operatively BECAUSE RCTs have indicated better outcomes in these pts.

ACOVE-3 quality indicators

Indicator #8: IF a vulnerable elder with a stroke has persistent dysphagia at 14 days, THEN a gastrostomy or jejunostomy tube should be considered for enteral feeding BECAUSE this method of feeding has improved outcomes compared to oral feeding.

Contributors to risk of malnutrition

The elderly are at higher risk of developing protein-calorie malnutrition and other vitamin and mineral deficiencies. The frequency of these events increases with advancing age due to problems such as poor dentition, loss of taste, difficulty swallowing, malabsorption, and drugnutrient interaction

Contributors to risk of malnutrition

Other physical limitations such as inability to obtain necessary food due to lack of transportation and dependence on others for shopping, lack of financial resources, and functional limitations can contribute to nutritional deficiencies

Contributors to risk of malnutrition

Non-perishable foods frequently contain high amounts of sodium and nitrates, and processing can remove vitamins. Many drugs cause anorexia, gustatory changes, and anosmia as major side effects. Medications can also interfere with nutrient availability

Risk Factors for Poor Nutrition Status

Alcohol or substance abuse Cognitive dysfunction Decreased exercise Depression, poor mental health Functional limitations Inadequate funds Limited education Limited mobility, transportation Medical problems, chronic diseases Medications Poor dentition Restricted diet, poor eating habits Social isolation
(see MEALS ON WHEELS on pocket card)

Physiology-the anorexia of aging

Physiology-the anorexia of aging

Physiology

Changes in physiology, metabolism, body composition, and physical function in the older patient may alter nutritional requirements, so that standards applicable to younger patient or middle-aged adults cannot be applied to the elderly

Physiology

Changes in body composition

Decreased bone mass Decreased lean mass

Decreased water content Increased total body fat (greater intra-abdominal fat stores)

Decline in organ function is highly variable among individuals and may affect assessment and intervention options

Physiology

Serum albumin is a recognized risk indicator for morbidity and mortality but is not an indicator of malnutrition because it lacks sensitivity and specificity. A modest decline does occur with aging Half-life is ~ 20 days Sensitive to hydration state and presence of inflammation, surgery, and other severe disease

Physiology

Hypoalbuminemia in the A. Community Setting Functional limitation Sarcopenia Increased health care use Mortality

Physiology

Hypoalbuminemia in the B. Hospital setting Increased length of stay Complications Readmissions Mortality

Physiology

There are some reports which express the use of caution with using albumin as a measurement of nutritional status in hospitalized patients. It is inversely correlated with markers of inflammatory activity (ESR, CRP) and can behave as an acute-phase reactant, with markedly reduced levels in the setting of acute illness.

Physiology

Prealbumin half-life ~ 48 hours Responds rather quickly to increased protein intake Controversial with regards to its use as a marker of malnutrition Best used in conjunction with other parameters (i.e. exam, BMI, CRP, hx of wt. loss, and various nutritional assessments) Also affected by changes in transcapillary escape due to infection, inflammation, etc.

Physiology

Cholesterol Serum cholesterol has been linked to nutritional status. Levels <160mg/dl have been detected in patients with malignancy or other severe disease states. Community-dwelling elderly with both hypoalbuminemia and hypocholesterolemia exhibit higher rates of functional decline and mortality than those with either one alone.

Drugs that can cause ANOREXIA

digoxin phenytoin SSRIs / lithium Ca++ channel blockers H2 receptor antagonists / PPIs Any chemotherapy metronidazole

narcotic analgesics K+ supplements furosemide ipratropium bromide theophylline spironolactone levodopa fluoxetine

Drugs can interfere with senses of taste and smell

More than 250 medications reportedly disturb gustatory sensation More than 40 drugs reportedly disturb the sense of olfaction A few of these agents have been objectively determined to affect these functions via experiments, clinical trials, or intensity scaling

Drugs That Interfere With Gustation (taste) and Olfaction (smell)

Gustation

Allopurinol Amitriptyline Ampicillin Baclofen Dexamethasone Diltiazem Enalapril Hydrochlorothiazide Imipramine Labetalol Mexiletine Ofloxacin Nifedipine Phenytoin Promethazine Propranolol Sulfamethoxazole Tetracyclines

Olfaction

Amitriptyline Codeine Dexamethasone Enalapril Flunisolide Flurbiprofen Hydromorphone Levamisole Morphine Pentamidine Propafenone

Drug-nutrient interactions

Many of the aforementioned drugs and others interfere with the absorption of various vitamins and minerals Examples: Antacids- Vitamin B12, folate, iron, total kcal Diuretics- Zn, Mg, Vitamin B6, K+, Cu Laxatives- Ca, Vitamins A, B2, B12, D, E, K

Drug-Nutrient Interaction
Drug
Alcohol Antacids Antibiotics, broad-spectrum Digoxin Diuretics Laxatives Lipid-binding resins Metformin Phenytoin/Salicylates SSRIs Trimethoprim

Reduced Nutrient Availability

Zinc, vitamins A, B1, B2, B6, folate, vitamin B12 Vitamin B12, folate, iron, total kcal Vitamin K Zinc, total kcal (via anorexia) Zinc, magnesium, vitamin B6, potassium, copper Calcium, vitamins A, B2, B12, D, E, K Vitamins A, D, E, K Vitamin B12, total kcal Vitamin D, folate/Vitamin C, folate Total kcal (via anorexia) Folate

Basic Nutritional Requirements for the Older Patient

Estimated total daily energy need (based on body weight): 25-30 kcal/kg/day Estimated total daily energy need (based on basal energy expenditure; BEE): Harris-Benedict Equation Male BEE = 66 + (13.7 x kg) + (5 x cm) (6.8 x age) Female BEE = 655.1 + (9.563 x kg) + (1.850 x cm) (4.676 x age)

Results should be multiplied by 1.5 to estimate energy expenditure of ill elderly patients

Basic Nutritional Requirements for the Older Patient

Carbohydrates should comprise 45-65% of total calories Fat should comprise 20-35% of total calories Protein should comprise 10-35% of total calories Fluid : 30ml/kg/day or 1ml per kcal intake

Basic Nutritional Requirements for the Older Patient

Estimation of protein: (0.8 to 1.5)gm/kg/day Restriction of these amounts may be indicated in renal or hepatic insufficiency Estimation of fiber: (complex carbohydrates are the preferred fiber source) Men: 30 gm/day Women: 21 gm/day
(see the 1-30-30 rule on the pocket card)

Nutritional Screening and Assessment

Nutrition Screening Initiative (NSI): collaborative effort of AAFP, ADA, and the National Council on Aging NSI completed a study in 1996, revealing evidence that older patients admitted to the hospital in poor nutritional states had longer stays and increased rates of complications than wellnourished patients.*

* Bagley, B; Nutrition and Health (Editorial); AFP, 57(5): March 1, 1998

Nutritional Screening and Assessment

The NSI developed a screening tool that can be completed by patients, family members, or a health care professional The tool consists of 10 questions which are scored and placed in 3 categories: No nutritional risk 0-2 points Moderate nutritional risk 3-5 points High nutritional risk >6 points

Nutritional Screening and Assessment

NSI (points apply to YES answers) I have an illness or condition that made me change the kind and/or amount of food I eat (2) I eat fewer than two meals per day (3) I eat few fruits or vegetables, or mild 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 3 or more different prescribed or OTC drugs per day (1) Without wanting to, I have lost or gained 10 or more pounds in the last six months (2) I am not always physically able to shop, cook and/or feed myself (2)

Nutritional Screening and Assessment

Mini Nutritional Assessment (MNA) is a validated screening and assessment tool for identifying elderly patients with or at risk for malnutrition Developed by the Nestl Research Center, in collaboration with hospital clinicians

Nutritional Screening and Assessment

The MNA obviates the need for blood tests to screen and monitor a patients nutritional status Composed of two sections: Screening and Assessment

Nutritional Screening and Assessment

MNA Screening: In the screening section, five questions are asked, and the patient's BMI (Body Mass Index) is calculated, using the patient's height and weight. From these six items, a score is calculated, which will indicate whether there is possible malnutrition Screening score: (max. 14 pts) > 12 pts Normal; not at risk < 11 pts Poss. malnutrition; go to assessment

Nutritional Screening and Assessment

MNA Assessment: Clarifies whether there is a future risk of malnutrition, or if malnourishment is currently present. The assessment section is comprised of 10 questions, and two anthropometric measures mid-arm circumference and calf circumference. Scoring (max. 16 pts); when added to screening score, total max is 30 pts. If total is 17-23.5 pts, pt is at risk of malnutrition and if <17 pts, the pt is malnourished.

Nutritional Screening and Assessment

The MNA has demonstrated acceptable internal consistency, inter-observer reliability, and validity in studies of community-dwelling, hospitalized, and nursing home elderly individuals around the world and in the U.S.

Beck, A., et al. European Journal of Clinical Nutrition. Nov 2001, Vol 55(11); 1028-33

Nutritional Screening and Assessment

Limitations of use of MNA: Lack of familiarity with the requirement of measuring both mid-arm and calf circumference

Nutritional Screening and Assessment

Geriatric Nutritional Risk Index (GNRI): requires measurements of height, albumin, and weight at admission (also ideal weight as calculated from the Lorentz equation). Nutritional risk is graded based on results of calculations. It is a more reliable prognostic indicator of morbidity and mortality in hospitalized elderly. Low albumin and elevated CRP correlate statistically with increased nutritional risk (stronger than with prealbumin)

Body Size Classification

Body Size Underweight Normal weight Overweight Obesity Extreme Obesity Body Mass Index (kg/m) < 18.5 18.5-24.9 25-29.9 30 40

Nutritional Syndromes

Undernutrition-3rd leading condition in hospital and home care sites and 4th leading condition in office practice and nursing homes for which QI efforts would improve the functional health of older persons.

Nutritional Syndromes

Undernutrition: it is often clinically difficult to physically distinguish cachexia from wasting Cachexia (REE is increased) Wasting (REE is decreased)
*REE Resting energy expenditure

Nutritional Syndromes

Obesity prevalence extends to the 60-70 age group Adverse outcomes associated with obesity include impaired functional status (esp. BMI>35), increased health care resource use and increased mortality Poor diet quality and micronutrient deficiencies are common in obese elderly pts., especially women who live alone

Nutritional Syndromes

In the older obese patient, the focus should be on attaining a healthy weight to promote improved function, overall health, and quality of life A combination of dietary change, behavior modification and increasing activity or exercise are appropriate for most elderly obese patients.

Nutritional Syndromes
However, homebound elderly are growing in number among the elderly obese. For those with frailty and obesity, the emphasis may be better placed on preservation of strength and flexibility rather than on weight reduction.

Nutritional interventions

PREVENTION is easier than treatment Intake improved by catering to food preferences; avoid therapeutic diets with no known clinical value Prepare patients for meals with hand/mouth care; proper positioning Assist those who need assistance Use herbs and spices to compensate for the losses of senses of taste and smell

Nutritional interventions

Avoid rushing through a meal Meals-On-Wheels wherever possible (Title III of Older Americans Act) Provide dietary supplements

Micronutrient supplements Calcium and vitamin D

(1200mg/800 I.U.)

Nutritional interventions

Vitamin E has not been shown to reduce the progression of Alzheimers disease or prevent coronary artery disease, but has been associated with a higher risk of hemorrhagic stroke; naturally occurring vitamins may do a better job of preventing cardiovascular disease and mortality.

Nutritional interventions

It has been suggested that multivitamins and antioxidants may help to prevent agerelated cataracts and macular degeneration Ask about and document all medications and supplements being taken. Review the necessity, safety, potential risks, and adverse effects with the patient.

Nutritional interventions

DRUG TREATMENT: Appetite stimulants Cytokine-modulating agents Trophic agents

Nutritional interventions

Appetite stimulants

mirtazapine (Remeron): 3.75-30mg PO at bedtime; enhances serotonin via antagonism of the 5-HT3 receptor

cyproheptadine (Periactin): 2-4mg PO orally with meals; serotonin and histamine antagonist with some anticholinergic properties and potential for confusion in the elderly

Nutritional interventions

Appetite stimulants

Megestrol (Megace) 320 800 mg PO in four divided doses. Wt. gain is primarily fat; associated with increased risk of DVT in nursing home patients Dronabinol (Marinol) 5-15mg/M2/day; a cannabinoid associated with somnolence and dysphoria in older persons

Ethical issues

For the nursing home patient, standards of care stipulate that a resident maintain acceptable parameters of nutritional status (weight, protein levels) unless the clinical condition is one wherein this is not possible, and a resident should receive a therapeutic diet when there is a problem.

Ethical issues

Adequate nutrition and hydration should always be provided to the elderly patient unless invasive nutritional support is refused by a fully-competent patient (document in written form that pt. has been informed of potential consequences of this choice with witnesses) or the terminally ill patient has executed a living will or advance directive that excludes artificial feeding in the event of unexpected death or terminal illness.

Ethical issues

Use caution with initiation of artificial nutrition and hydration in demented patients. This has not been demonstrated to improve life expectancy or quality of life. Appropriate counseling of patient, family, and/or surrogate of the consequences of withholding nutrition and feeding is obligatory! Consider palliative care in the setting of severe or end-stage dementia, and in those cases where living wills specify the withholding of artificial nutrition and hydration.

SUMMARY

Malnutrition is remarkably common in the older adult The risk of malnutrition in the elderly is high even in the absence of clinical or social risk factors due to the primitive so-called anorexia of aging. Limitations in functional capacity, dentition, and support systems contribute to the problem Medications can and do adversely impact nutritional status Use of one of the screening tools can identify undernourished individuals whose problems are amenable to intervention

SUMMARY

Prevention is best, but implementation of interventions as early as possible (< 3 days since diagnosis) enhance more favorable outcomes Prealbumin alone is probably not a good parameter for identifying malnutrition but when combined with other measures such as serum albumin, cholesterol, BMI, or CRP it can be more useful. Low albumin and elevated CRP can be significant risk indicators while not being diagnostic of the presence of malnutrition.

SUMMARY

Clarify patients advance directives whenever possible before initiating tube feedings or other artificial nutrition and hydration. Only a few of the quality indicators for malnutrition have evidence to support them, but the 8 ACOVE indicators weve discussed can serve as measures that may differentiate between quality and substandard care.

References

Nestle Nutrition; MNA (Mini Nutritional Assessment) http://www.nestle-nutrition.com/tools/mna.aspx Malnutrition, Chap. 24; Geriatrics Review Syllabus, Sixth Edition; American Geriatrics Society, 2006: PP 174-80 Reuben, D. Quality Indicators for Malnutrition for Vulnerable Community-Dwelling and Hospitalized Older Persons; RAND Health; http://www.rand.org/health/projects/acove/quality_indicators.html Bagley, B. Nutrition and Health-Editorial; American Family Physician; March 1, 1998; 57(5)+Beck, A.M., et al. A six months prospective follow-up of 65+ y-old patients from general practice classified according to nutritional risk by the Mini Nutritional Assessment; Euro J of Clin Nutrition, 2001, Vol. 55: 1028-33 Lantz, M.S. Failure to Thrive; Clinical Geriatrics, March 2005, 13(3): pp 20-23 Kiseljak-Vassiliades, K., et al. Basic Nutrition for Successful Aging: Part 1; Clinical Geriatrics, April 2006, 14(4):pp 16-24 Shenkin, A. Serum Prealbumin: Is It a Marker of Nutritional Status or of Risk of Malnutrition?-Editorial; Clinical Chemistry: 52(12), 2006 Devoto, G., et al. Prealbumin Serum Concentrations as a Useful Tool in the Assessment of malnutrition in Hospitalized Patients. Clinical Chemistry: 52(12):2281-85, 2006 Francesco, V.D., et al. The Anorexia of Aging; Digestive Diseases 25(2):129-137; 2007