Download 62a6b927421873e9148b472c

yes no Was this document useful for you?
   Thank you for your participation!

* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project

Document related concepts
no text concepts found
Elizabeth Maue
Medical Nutrition Therapy: A Case Study Approach 3rd ed.
Case 5 – Polypharmacy of the Elderly: Drug-Nutrient Interactions
Instructions: Please complete each question listed below. Be thorough in answering these
questions. With any calculations, please show your work. Use any resources available to
complete these questions; chapter 11 of your textbook will help you complete this assignment.
Make sure to look up any unfamiliar terms or concepts. Answers can be typed directly onto
this document and should be uploaded to D2L by February 1st at 8 pm.
I. Understanding the Disease and Pathophysiology (one point each)
1. Identify each of the medical diagnoses (reasons for admission) for Mr. Kaufman.
-Mr. Kaufman was admitted into the hospital because of increased confusion.
-Prior to this hospital visit, Mr. Kaufman was diagnosed with and/or still treating:
 Cancer: Prostate
 Chest pain
 High Blood Pressure
 Arthritis
 Circulation problems
 Easy bleeding/bruising/anemia
 Diabetes: Type 2
 Kidney /Urinary problems
 Hearing problems
 Back pain
2. Identify which of these may affect cardiac function, liver function, and renal function.
-Cardiac function might be affected by: chest pains, high blood pressure, circulation problems, anemia, type 2 diabetes, and
kidney/urinary problems.
-Liver function might be affected by his type 2 diabetes, past prostate cancer, and also kidney/urinary problems
-Renal function might be affected by: high blood pressure, type 2 diabetes, and kidney/urinary problems
Are there also normal changes in renal function that occur with aging?
There are normal changes that occur in regards to renal function as we age. The kidneys are designed to filter the blood
and remove waste from the body. The kidneys lose function, which means there could be common problems associated
with that. The kidneys begin to decrease glomerular filtration rate and also renal blood flow. Older people are at higher risk
for urinary tract problems as well. Renal functions can be impaired from the following problems: kidney problems, high
blood pressure, diabetes, obesity, and many others. Being elderly puts Mr. Kaufman at risk for decreased renal function but
so do his high blood pressure, obesity, and diabetes.
Define polypharmacy. Do you think that Mr. Kaufman’s medications represent polypharmacy? Why is
polypharmacy a concern in the elderly?
-Polypharmacy is when an individual is taking several medications, typically over four. Polypharmacy is a problem that
associated with the elderly population, 65 and older. Polypharmacy is a concern because elderly could be confused by
the medications, which could cause negative outcomes. Some negative outcomes of polypharmacy could be:
overdosing, loss of balance, which causes falls and fractures, cognitive disorders, depression, and also mortality. I
believe that Mr. Kaufman is a representation of polypharmacy. When Mr. Kaufman was being admitted into the
hospital he listed eleven medications he takes. The admission database also states “patient is confused” when he was
asked about his medications. His daughter also does not know about his medications. I believe that it is a red flag that
Mr. Kaufman does not know his medications.
Elizabeth Maue
II. Understanding the Nutrition Therapy (two points each)
Describe the potential nutritional complications secondary to pharmacotherapy.
There are many complications when it comes to taking medications at any age. There are side effects to all
medications. Common side effects are vomiting, nausea, increased or decreased appetite, constipation, or even diarrhea.
Many medications could affect saliva production, which could cause dry mouth, taste differences, decreased appetitie, and
even difficulty eating. You have to be able to decide whether the side effects are worth taking the medication that is used
to treat something else. Medications are used to help treat many different illnesses/disease but sometimes the side effects
cause other problems that need to be treated with other medications, which could cause polypharmacy.
Describe the potential effect of nutrition on the action of medications.
How much food we eat, types of foods, and when we eat all can play a role on how well our medications work.
Different types of foods can have an effect on how fast the medication is absorbed, decreases the medications potential, or
even the interaction. It isn’t just food either, some drinks like alcohol and caffeinated drinks can affect medications. Some
medications also need food to bind so they can be absorbed into the body fully. On the other hand, some medications are
not absorbed fully because they are competing with foods at an absorption site. You want to get the most out of your
prescribed medication so we must be aware the different foods that can effect medications positively or negatively. If
unsure about food and medication interactions a physician or pharmacist would be able to help.
Nutrition Assessment
A. Evaluation of Weight/Body Composition (two points each)
Mr. Kaufman is 5’5” tall and weighs 196 lbs. calculate his body mass index. How would you interpret this
value? Should any adjustments be made in the interpretation to account for his age?
BMI: 196/652 X703 = 32.45
Obese BMI is anything 30 and above, Mr. Kaufman falls into the obese category. I believe that this is something that
you have to look at the whole picture when interpreting his BMI. Mr. Kaufman has made a significant change when it comes
to his weight in the last three years and he is also 85 years old. I would suggest that Mr. Kaufman just maintains his weight
so that he can live out his years in happiness. Mr. Kaufman is already elderly with these chronic disease, my hopes would be
to get his diseases under control. I would try to give him some options when it came to snacking and consuming fluids. I
would not proceed with any nutrition intervention at this time because of his age and disease states.
8. Calculate Mr. Kaufman’s percent usual body weight. Interpret the significance of this assessment.
Current weight: 196lbs
Weight 3 years ago: 225lbs
Percent of weight change = UBW- Current weight/UBW x 100%
225lbs -196lbs/225lbs x100% = 12.89%
100-12.89= 87.11% Deficit
Mr. Kaufman’s %UBW was 87.11%, which falls into mild deficit (85-95). He lost this weight over a period of three years.
This weight loss is not an area of concern since it was an extended period of time and most likely benefited him.
Elizabeth Maue
When completing a nutritional assessment on an older individual, should specific changes in body
composition and energy requirements be considered? If so, which changes?
I think that it is crucial to assess an older individuals nutrition status. At the same time I believe there are certain
questions that are more important when talking with an elderly person. Food intake, weight loss, mobility, illnesses or
disease, and other stressors would be important to find out. We know that with the elderly their mobility and physical
activity goes down, which would mean impact their energy requirements and protein intake. As we age we lose muscle
mass, which has an impact on our nutrition and also our physical activity. We also need to take into account for the
individual’s limitations; cancer, diseases, injuries, pressure ulcers, and age in general. I do not believe in pushing an older
individual into losing weight or restricting calories. At this point in their lives they have lived their life and already done the
damage. I think It would be fine to explain nutrition to an elderly person but not push them one way or another. I believe
that this is something that needs to be taken into account based on the individual specifically.
B. Calculation of Nutrient Requirements (three points)
10. Calculate energy and protein requirements for Mr. Kaufman. What factors should you consider when
estimating his requirements?
Energy Requirements:
-Short Cut Method: Obese Adult Equation: Weight (kg) x 16-20 kcals/kg
196/2.2 = 89.09 kg 89.09x 16 = 1425 kcals
89.09 x 20 = 1781.80 kcals
Mr. Kaufman’s energy needs are between 1425-1781 kcals a day. His treatment plan says that he should be given a diet of
1,800 kcals a day based on the American Diabetic Associations diet.
-Mifflin-Jeor Equation:
(9.99 x weight (kg)) + (6.25 x height (cm)) - (4.92 x age) +5 = energy needs
(9.99 x 89.09kg) + (6.25 x 165.1cm) – (4.92 x 85 years old) + 5
(890) + (1031.075) - (418) +5 = 1,498.7 kcal
Protein Needs:
-Protein needs for Mr. Kaufman: He should be given a diet that takes into account his age.
> 65 years of age (elderly) = 1g/kg of body weight
Mr. Kaufman is 196 lbs. 196/2.2= 89.09 kg
1g x 89.09kg = 89.09g of protein
When assessing Mr. Kaufman you notice that he is an elderly gentleman that is obese and sedentary. Mr. Kaufman’s
physical activity, age, and also body mass index all are contributing factors when deciding on his energy needs. I believe
that Mr. Kaufman is sedentary because he does not perform any sort of exercise. He does volunteer at the local school and
church, which keeps him active. When deciding on Mr. Kaufman’s calories I would recommend the Miffilin-Jeor results of
1,498 calories. I believe that this amount of calories would allow Mr. Kaufman to maintain his weight while having enough
energy for his volunteer work and daily living. Dr. Curtis Martin gave the treatment plan of 1,800 calories based on the
American Diabetic Association while he stayed in the hospital. I believe that this might be too many calories and even
exceeds his requirements based on the short cut energy requirement equation. When deciding on Mr. Kaufman’s protein
needs you should take into account that he is elderly (>65 years of age). Since he has less activity than a younger person he
needs protein to sustain his lean body mass. Mr. Kaufman should consume 89.09g of protein.
Elizabeth Maue
C. Intake Domain (three points each)
11. There are several ways to estimate fluid needs. Calculate Mr. Kaufman’s fluid needs by using at least two of
these methods. From your evaluation of his usual intake, do you think he is getting enough fluids? Is this a
common problem in aging?
-Mr. Kaufman’s fluid needs based on his age:
He falls into the above 65 category because he is 85 years old. He should be getting 25-30 mL/kg.
Mr. Kaufman is 89.09 kg (196/2.2).
25 x 89.09 = 2,227.25mL 30 x 89.09 =2,672.7mL
Mr. Kaufman based on his age should be consuming anywhere
between 2,227.25-2,672.7mL of fluids.
-Fluids based on calories:
1mL of fluid per kcal
Mr. Kaufman is recommended to have 1,498.7 calories. If this equation wants 1mL per kcal, Mr. Kaufman would be
recommended to have 1,498.7mL of fluid.
When looking at Mr. Kaufman’s initial assessment there were are few things that stood out that led me to believe he
was not receiving the proper fluid intake; His physical exam & concerns from his daughter. During his physical exam his
membranes were dry in his mouth. The daughter also is concerned about her father’s fluid intake “her biggest concern
nutritionally is that her father never seems to drink fluids except at mealtime, and she is worried that he doesn’t get
enough.” His daughter will pour him a glass of water between meals but he only takes a few sips. When looking at Mr.
Kaufman’s usual dietary intake his fluids were:
½ cup of cranberry juice (1/2 cup = 118.294mL)
3 cups of coffee (3 x 236.588mL = 709.764mL)
(2) 6-8 ounces of iced tea (1 ounce = 29.5735mL 7oz x 29.5735mL= 207.015mL x 2 = 414.03)
(118.294 + 709.764 + 414.03)
Mr. Kaufman’s usual fluid intake = 1,241.78mL of fluids
After estimating what Mr. Kaufman’s usual fluid intake was from liquids alone (1,241.78mL) I used it to help determine
whether or not I believed Mr. Kaufman was receiving enough fluids. I determined that Mr. Kaufman was not receiving
enough liquids based on my estimated fluid intakes. When calculating his fluid needs I received two different
measurements. The estimates were different because one formula was based on his age and another based on his calorie
intake. Using both estimates Mr. Kaufman still fell short when it comes to his daily fluid intake. I believe that since Mr.
Kaufman has an issue getting enough fluids that I would recommend that he receive 2,227-2,672mL of fluids daily. There
would have to be further nutrition education to help Mr. Kaufman understand the benefits of fluids and ways to consume
It is a common problem when it comes to the elderly population and the inadequate intake of fluids. There are many
reasons behind this problem. With aging we have a decreased sensation of thirst. Also kidney’s functions are decreasing
with age making it harder to retain fluids because of incontinence. The sensation of thirst and lack of kidney function can
put the elderly population at risk for dehydration. Depending on other factors of the elderly persons health it might be
difficult for the person to swallow liquids. Fluids need to be a priority for elderly but because of other issues, liquids might
be forgotten.
12. Evaluate Mr. Kaufman’s usual intake for both caloric and protein intake. How does it compare to the MyPlate
Recommendations based on equations:
-Calorie needs: 1,498 calories
-Protein needs: 89g of protein
Usual intake based on Dietary intake from assessment: (rough estimate) = 2,081kcal, 7oz of meat
-Egg beaters: 12oz (167kcal)
-1 TBSP shredded cheese (55kcal)
-2 slices of bacon (220kcal)
Elizabeth Maue
-1 slice of toast (75 kcal)
- ½ cup cranberry juice (68kcal)
-3 cups of coffee with fat free creamer (7kcal + 38kcal)
- 2-3 ounces of meat (chicken: 223kcal)
-1-2 vegetables (½ cup each) (peas: 59kcal) (corn: 66kcal)
-Roll (68kcal)
-½ cup of fruit (peaches: 8kcal)
-6-8 oz of iced tea (7oz: 79kcal)
-3-4 oz of meat (chicken: 223kcal)
-1 cup rice (205kcal)
-1 slice of bread (80kcal)
- ½ cup of fruit (sliced strawberries: 122kcal)
-6-8 oz of iced tea (7oz: 79kcal)
-Sugar free jello (15kcal)
-Low fat yogurt (110kcal)
-Popcorn (114kcal)
MyPlate Recommendations: 1600 calories for Mr. Kaufman
-5oz of grains
-2cups of vegetables
-1 ½ cup of fruits
-3 cups of dairy
-5 oz of protein
When comparing all of the recommendations against Mr. Kaufman’s daily intake there are some differences. I would
agree with MyPlate for the calories. The estimated calorie recommendation I received from the Mifflin-Jeor Equation is not
much different from the 1,600 calories from MyPlate. Also when doing the short cut equation for Mr. Kaufman’s energy
needs I received 1425-1781 kcals a day, which is in line with MyPlate’s recommendations. As it is now Mr. Kaufman eats
around 2,000 calories daily, which is over his recommended calorie needs. I do not think I agree with MyPlates
recommendation for protein. MyPlate is very broad, they have a broad 1600 calorie intake for men 18 years and older. I
think that it really needs to be specific for cases like Mr. Kaufman’s. Mr. Kaufman being older needs to receive at least 89g
of protein to sustain a healthy lifestyle; I don’t think the 5oz of protein is cutting it for someone his age. I believe the my
plate would be a helpful resource for Mr. Kaufman if you ignore the protein portion and tailor it to his recommendation.
D. Clinical Domain (four points each)
13. Mr. Kaufman was diagnosed with mild metabolic alkalosis and dehydration. What is metabolic alkalosis?
Read Mr. Kaufman’s history and physical. What signs and symptoms does the patient present with that may
be consistent with metabolic alkalosis and dehydration? Explain.
Metabolic Alkalosis is a condition where bicarbonate is elevated in the blood, which causes a disturbance in pH. This
disturbance is caused by loss of too much acid or gaining too much base. Alkalosis could be involving a fluid imbalance.
There are many reasons that this could happen. Loss of acid, vomiting, hypokalemia, intravenous therapy, blood transfusion
and excessive or chronic use of anti acids could be the cause. There are very apparent signs and symptoms and then there
are also symptoms that are not so apparent. Some symptoms of alkalosis are: confusion, muscle twitching, vomiting, hand
tremor, numbness, and fever. Mr. Kaufman when he came into the hospital was admitted for confusion. Also listed in Mr.
Kaufman’s assessment was that he had peripheral neuropathy, this could be because of his diabetes or also because of the
metabolic alkalosis. Different medications can also cause metabolic alkalosis. Some diuretics can cause potassium
depletion, which can induce this problem, Mr. Kaufman is on a diuretic: Furosemide. Another medication that could have
played a role would be the anti acids: Sodium bicarbonate. Mr. Kaufman might have become even more dehydrated
because he was urinating a lot due to the loss of acid, which would have been caused by the metabolic alkalosis. Mr.
Kaufman should once again drink more fluids.
Elizabeth Maue
14. What laboratory values support his medical history of renal insufficiency? What laboratory value(s) support
this diagnosis of metabolic alkalosis? Which are consistent with dehydration? What laboratory values support
his medical history of type 2 diabetes mellitus?
3.5–5 g/dL
3.5–5.5 mEq/L
285–295 mmol/kg/H2O
70–110 mg/dL
8–18 mg/dL
0.6–1.2 mg/dL
35–45 mm Hg
23–30 mmol/L
24–28 mEq/L
Mr. Kaufman’s Value
3.4 L
310 H
172 H
32 H
1.5 H
8.2 H
7.47 H
46 H
32 H
High levels: Osmolality, Glucose, BUN, Creatinine, HbA1c, pH, pCo2, CO2, HCO3
Low levels: Albumin, Potassium
Renal insufficiency labs: BUN, Creatinine, Albumin, HCO3
 BUN: (Blood urea nitrogen) this could show renal insufficiency because it is elevated during kidney dysfunction or
failure. Mr. Kaufman’s BUN lab result is elvated pretty high. Normal range is 8-18mg/dL and his is 32mg/dL.
 Creatinine: Mr. Kaufman’s level of Creatinine is elevated also, this could be elevated during kidney dysfunction or
 Albumin: Mr. Kaufman’s value of serum albumin was low. The reason for this could be because of edema, severe
liver failure or even nephrotic syndrome. Nephrotic syndrome is caused by different disorders that damage the
kidneys, this causes too much protein to be excreted in the urine.
 Potassium: He has low potassium of hypokalemia. This is because of high renal losses due to diuretics.
 HCO3: this is regulated by the kidnesy and is supposed to keep acids and bases equal. Mr. Kaufman’s HCO3 levels
were increased because of lack of kidney functions which could have also caused his alkalosis.
Metabolic alkalosis labs: Potassium, CO2, pH, Pco2
 Potassium: With high renal losses this could cause a decrease in potassium values. When there is a decrease in
potassium values it could cause an imbalance in the pH causing metabolic alkalosis.
 CO2: This lab tests to check the carbon dioxide content in the blood. The carbon dioxide content in the blood might
be associated with the pH in the blood, which would have been raised because of the metabolic alkaloisis.
 pH: This measures the hydrogen ion concentration. When this is increased like Mr. Kaufman’s is, the pH of the
blood is more acidic.
 Pco2:When there is a metabolic disturbance there is an increase in Pco2 levels. This lab is able to measure the
partial pressure of CO2 in the blood. Mr. Kaufmans Pco2 is increased because his body is trying to retain the CO2
and decrease the pH in his body from the metabolic alkalosis.
 HCO3: Mr. Kaufman’s kidneys were unable to keep the equilibrium in the body, which would have thrown off the
Dehydration labs: BUN, Creatinine, osmolality
 BUN: This could be elevated because of renal insufficiency but also because of his dehydration status.
 Creatinine: This could be elevated because of his renal insufficiency but also because of his dehydration status.
Elizabeth Maue
Osmolality: This lab measure he number of dissolved particles in the serum/plasma and also the amount of free
water. When there isn’t enough water in the blood the particles increase. Mr. Kaufman’s levels of osmolality were
high which could be caused by dehydration.
Type 2 diabetes labs: HBA1c, Osmolality, Glucose
 HBA1c: a lab that would show long-term glucose control, which reflects the plasma glucose for the past two to
three months. This would show how well Mr. Kaufman is controlling his diabetes. Mr. Kaufman’s HBa1c value was
172mg/dL, which is high, compared to the normal value of 70-110mg/dL. This would be a 7% on the A1c test.
 Osmolality: This could also be in indicator for diabetes. In this case Mr. Kaufman’s osmolality was high and could
have been from either dehydration or his uncontrolled diabetes.
 Glucose: Mr. Kaufman’s glucose levels were high. We already know that he has type two diabetes. When he
received his lab work he might not have been fasting. There are many factors that could have had an effect on his
lab work. We also know that Mr. Kaufman is not great at controlling his diabetes.
15. Using the following table, list all the medications that Mr. Kaufman was taking at home. Identify the function
of each medication and any potential drug-drug or drug-nutrient interactions.
Drug–Drug Interaction
-Anti hypertensive:
treats high blood
-Cyclosporine -Diuretic
-Lithium -Rifampin
-Aspirin -Ibuprofen -celecoxib
-Anti secretory
-Anti gerd: used to
decrease acid in the
-Anti epileptic: treats
-Clopidogrel –Cilostazol –Valium
-Digoxin –Iron –Antibiotics
-Diuretic –Seizure medication
-HIV or AIDs medications: Atazanavir,
nelfinavir, ripivirine
-Hydrocodone, Morphine, Naproxen
-Loop diuretic
-Anti hypertensive
-Prevents body from
absorbing too much salt
-treats fluid retention
-Cyclosporine -Salicylates(asprin)
-Ethacrynic acid -Steroids
-Heart or blood pressure medicines
-It dilates blood vessels
-Prevents chest pain
-Revatio -Tizandine -Viagra -Tadafil
-Zanaflex -Oraqix -Levitra -Cialis -Emla
-Avanafil -Lidocain -Adempas
-Nithiodote -Prilocaine -Revatio -Staxyn
-Sodium Nitrate -Stendra -Sidenafil
-Potassium containing
Elizabeth Maue
Drug–Drug Interaction
-Anti acid
-helps relieve heart burn
-Alkalinizing agent
-If using as an antiacid, take
after meals with water
-Need to consider a low
sodium diet
-Anti pyretic
-Anti arthritic
-To prevent
cerebrovascular accident
-used to reduce fever,
inflammation, and treat
-Antidepressants: citalopram,
escitalopram, fluoxetine (Prozac), Zoloft
-blood thinners: warfarin, Coumadin
-pepto bismol
-Pamperine cramp formula
-Nuprine Backache caplet
-To provide vitamins that
aren’t received through
the diet
-Vitamines A, D, E, K
-Tretinoin or isotretinoin
-Sulfa drug
-Diuretic or water pill
-Non steroidal anti inflammatory:
ibuprofen (advil, motrin),
Naproxen(aleve), celecoxib, diclofenac,
indomethacin, meloxicam
-Avoid taking with milk or
dairy products
-Avoid salt if the
multivitamin has potassium
in it
NPH and
regular insulin
-Anti diabetic: lowers
levels of glucose in the
-Albuterol -Clonidine -atenolol
-Resperpine –Carvedilol -Labetalol
-Meoprolol -nadolol -Nebivolol
-propranolol –Sotalol
-Anti depressant
-Also used to treat:
insomnia, aggression,
panic attacks
-Any other antidepressants
-Antibiotic: azithromycin, clarithromycin,
levofloxacin, moxifloxacin, petamidine
-Cancer medicines: arsenic trioxide,
-Heart rhymic medicines: amiodarone,
disopyramide, dofetilide, dronedarone,
-Anti malaria medication: chloroquine,
-Psychiatric disorder medicine:
chlorpromazine, haloperidol, pimozide
-Anti hyperlipidemic
-Lowers cholesterol and
triglycerides in blood
-Used to lower risk of
stroke, heart attack,
heart complications with
people that have
diabetes, coronary heart
-Grape fruit & its juice