Download Mr. Kaufman`s Value - Dietetic Portfolio

Erin Baas
KNH 411
Case 5: Polypharmacy of the Elderly
Case Questions
I. Understanding the Disease and Pathophysiology
1. Identify each of the medical diagnoses for Mr. Kaufman.
a. The medical diagnoses for Mr. Kaufman include CAD, type 2 DM, peripheral
neuropathy, renal insufficiency, and osteoarthritis. He also has a history of
diverticulitis/diverticulosis and prostate cancer.
2. Identify which of these may affect cardiac function, liver function, and renal function.
a. CAD, type 2 DM may affect his cardiac function. His liver function may be affected
from the prostate cancer, and his renal function may be affected by type 2 DM, renal
insufficiency, and osteoarthritis.
3. Are there also normal changes in renal function that occur with aging?
a. Yes, there are normal changed in renal function that occur with aging. As the kidneys
age, the number of filtering units (nephrons) decreases. These nephrons are what filter
waste material from the blood. The overall amount of kidney tissue also decreases. The
blood vessels supplying the kidneys can also harden, causing the kidneys to filter blood
at a slower rate. Aging can also cause changes in the bladder. As the bladder walls age,
the elastic tissue becomes tough and the bladder becomes less stretchy. The bladder
muscles may also weaken, causing the bladder to not empty completely when
urinating. These changes in the kidneys may cause an elderly persons ability to hold
onto water. Dehydration occurs more readily because of a less sense of thirst, in turn
causing a decrease in overall fluid intake.
(Langan, 2010)
4. Define polypharmacy. Do you think that Mr. Kaufman’s medications represent
polypharmacy? Why is polypharmacy a concern in the elderly?
a. Polypharmacy is the administration of many drugs simultaneously, usually meaning
that a patient is receiving an excessive number of medications. Polypharmacy may
negatively affect adherence to the pressure ulcer treatment plan. Yes, I do think Mr.
Kaufman’s medications represent polypharmacy, as he is taking 11, including a
multivitamin, all at the same time. Polypharmacy is a concern in the elderly for a
number of reasons. As the body ages, it processes medications differently. Medications
tend to stay in the system longer because absorption rates are slower. Some
medications are highly concentrated in parts of the body because of poor circulation.
There is decreased cardiac output, and the liver may shrink, which can affect
metabolism. How the drugs are excreted may be affected due to decreased renal
function. Elderly persons may also be affected by polypharmacy through negative drug
reactions that can cause loss of appetite, confusion, urinary problems, etc.
(Pervin, 2008)
II. Understanding the Nutrition Therapy
5. Describe the potential nutrition complications secondary to pharmacotherapy.
a. Potential nutrition complications that could occur with pharmacotherapy include loss
of appetite, weight loss, lean tissue loss, decreased absorption of nutrients, etc.
(Chernoff, 2008)
6. Describe the potential effect of nutrition on the action of the medications.
a. Good nutrition with medications could create better and/or faster recovery for
individuals. Good nutrition can also help to reduce some of the side affects the drugs
may bring about on an individual.
(Dube, 2009)
III. Nutrition Assessment
A. Evaluation of Weight/Body Composition
7. 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?
a. Weight kg = 196 / 2.2 = 89.1 kg
Height = 65 inches x 2.54 = 162.56 cm / 100 = 1.65 m
BMI = kg/m^2 = 89.1 / 1.65^2 = 32.7 kg/m^2
I would interpret this value as obese, as obesity is categorized as BMIs ranging from
30.0-34.9 kg/m^2. Men’s BMIs gradually increase with age until after 50 and 60 when a
gradual decrease starts to occur. However, at Mr. Kaufman’s old age, he would still be
categorized as obese.
(Halls, 2008)
8. Calculate Mr. Kaufman’s percent usual body weight. Interpret the significance of this
assessment.
a. Mr. Kaufman’s usual body weight is between 195-225 lbs and his current weight is
196 lbs.
%UBW = (actual body weight / usual body weight) x 100
= (196 lbs / 195 lbs) x 100 = 101%
= (196 lbs / 225 lbs) x 100 = 87.1 %
Mr. Kaufman’s %UBW is between 87-101%. However, he is currently closest to his
lower UBW. It is good that he has lost weight, as losing weight will help with cardiac
function and his type 2 DM. It would be helpful for him to continue to lose weight in a
healthy manner.
9. In an older individual, what specific changes occur in body composition and energy
requirements that may need to be taken into consideration when completing a nutritional
assessment?
a. Lean muscle mass will decrease as age increases, which in turn can cause percentage
of body fat to increase. More disease risks are associated with an increase of body fat
such as diabetes and heart disease. These need to be taken into consideration when
completing a nutritional assessment, as caloric needs are very closely connected to the
amount of lean, metabolizing muscle mass in the body. A decrease in bone mass is also
likely to occur in older individuals, especially women. To avoid this decrease and
osteoporosis, requirements for calcium and vitamin D increase.
(Epsy, 2012)
B. Calculation of Nutrient Requirements
10. Calculate energy and protein requirements for Mr. Kaufman. Identify the formula/calculation
method you used and explain the rationale for using it. What factors should you consider
when estimating his requirements?
a. Energy requirements:
TEE = 1086 - 10.1 x age + PA x (13.7 x weight(kg) + 416 x height(m))
PA = sedentary = 1
TEE = 1086 - 10.1 x (85) + 1 x (13.7 x (89.1) + 416 x (1.65))
TEE = 2,135 kcals/day to maintain current weight
I chose to use this equation because it is specific to men ages 19+ who are
overweight/obese.
Protein requirements:
.8 g/kg = .8 g x 89.1 kg = 71 grams of protein/day
1.0 g/kg = 1.0 g x 89.1 kg = 89 grams of protein/day
Because of Mr. Kaufman’s old age, he should really increase his protein intake to try to
prevent bone and muscle decreases.
(Kerstetter, Rodriguez, Insogna & Gaffney-Stomberg, 2009)
C. Intake Domain
11. Mr. Kaufman’s daughter expressed concern regarding his fluid intake. Is this a common
problem in again? Explain.
a. Yes, this can be a common problem in aging. Because illnesses and medications can
affect the kidneys abilities to function properly, an elderly person may not have the
ability to hold onto water properly. These changes in the kidneys along with a
decreased sense of thirst in the elderly can cause dehydration. Dehydration can also
progress due to a reduction in fluid intake if the elderly individual is trying to attempt
to reduce bladder control problems.
(Langan, 2010)
12. There are several ways to estimate fluid needs. Calculate Mr. Kaufman’s fluid needs by using
at least two of these methods. How do they compare? From your evaluation of his usual
intake, do you think he is getting enough fluids?
a. Method 1:
30-35 mL/kg = 30 mL x 89.1 kg = 2,673 mL/day
= 35 mL x 89.1 kg = 3,118 mL/day
Between 2,600-3,200 mL/day
Method 2 :
1-1.5 cc/kcal = 1 cc x 2,135 kcal = 2,135 cc’s/day
= 1.5 cc x 2,135 kcal = 3,203 cc’s/day
Between 2,100-3,200 cc’s fluid per day
The second method has a wider range of recommended fluid intake, but they both
recommend around the same amount. Looking at Mr. Kaufman’s usual intake, he is not
taking in nearly enough fluids as he should be.
13. Evaluate Mr. Kaufman’s usual intake for both caloric and protein intake. How does it
compare to the MyPyramid recommendations?
a. Caloric Intake: 2,400 kcals
Protein Intake: 116.7 grams
Compared to the MyPyramid recommendations, Mr. Kaufman’s caloric intake is over
what it should be. His intake should be around 1800 kcals. His protein intake is high, but
adequate, as he should be getting 15-35% of his calories from protein, or around 5.5
ounces each day.
14. From the information gathered within the intake domain, list Mr. Kaufman’s possible
nutrition problems using the diagnostic term.
a. NI-1.5: Excessive energy intake
NI-3.1: Inadequate fluid intake
NI-5.8.6: Inadequate fiber intake
NI-5.9.1: Inadequate vitamin intake (D, E)
NI-5.9.2: Excessive vitamin intake (A, B12, C, riboflavin)
NI-5.10.1: Inadequate mineral intake (calcium, magnesium, potassium)
NI-5.10.2: Excessive mineral intake (iron, phosphorus, sodium, zinc)
(http://www.adancm.com/vault/IDNT%20e3%20NDTerms-NCM.pdf)
15. Do you think Mr. Kaufman needs to take a multivitamin? In general, do needs for vitamins
and minerals change with aging? What reference would you use to determine recommended
amounts of the micronutrients?
a. Because Mr. Kaufman’s takes so many other medications, it would be somewhat
impractical to give him another medication to take on a daily basis. It would be best for
Mr. Kaufman to be educated through nutrition therapy on how he can increase and/or
decrease specific vitamins/minerals through his diet. The need for vitamins and
minerals does not really change with aging. However, it is crucial that elderly
individuals focus more on taking in close to 100% of the RDA for vitamins and
minerals, as this will only increase their health status and prevent illness and disease.
D. Clinical Domain
16. 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.
a. Metabolic Alkalosis is a clinical state marked by decreased amounts of acid or
increased amounts of base bicarbonate. This causes the pH of the blood to be elevated
beyond the normal range. Metabolic Alkalosis can result in muscle weakness,
irritability, confusion, muscle twitching, slow and shallow respirations, and convulsive
seizures. Mr. Kaufman’s very low fluid intake may give reason for dehydration, and
his confusion is consistent with metabolic alkalosis.
("Terms and definitions," 2011)
17. What laboratory values report 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?
a. The lab values that report Mr. Kaufman’s renal insufficiency are his high serum
creatine level, his high blood pressure, and high BUN level. His high pH level support
his diagnosis of metabolic alkalosis. His high BUN level is also consistent with his
dehydration, as a higher BUN level shows his kidneys aren’t functioning as well as
they should. Mr. Kaufman’s high glucose and HbA1c levels are supportive of his type
2 DM.
Laboratory
Normal
Mr. Kaufman’s Value
Albumin
3.5-5 g/dL
3.4 g/dL
Potassium
3.5-5.5 mEq/L
3.4 mEq/L
Osmolality
285-295 mmol/kg/H2O
310 mmol/kg/H2O
Glucose
70-110 mg/dL
172 mg/dL
BUN
8-18 mg/dL
32 mg/dL
Creatine
0.6-1.2 mg/dL
1.5 mg/dL
HbA1c
3.9-5.2%
8.2%
pH
7.35-7.45
7.47
pCO2
35-45 mm Hg
46 mm Hg
CO2
23-30 mmol/L
31 mmol/L
HCO3
24-28 mEq/L
32 mEq/L
18. Using the following table, list all the medications that Mr. Kaufman was taking at home.
Identify the function of each medication.
Medication
Function
Drug-Drug Interaction
Drug-Nutrient
Interaction
Diovan
treat high blood pressure
Taking with NSAIDs
could result in reduced
kidney function and
reduce overall effect of
diovan.
Don’t combine with
potassium supplements,
could cause hyperkalemia.
Prilosec
Treats acid-induced
inflammation and ulcers
of the stomach and
duodenum (ex: GERD)
Can be negatively
affected with taking
aspirin and zocor.
Affects iron and B12
uptake
Neurontin
Pain reliever and seizure
control
Can be interfered with
when taking aspirin and
prilosec
Do not take with alcohol
or magnesium
supplements
Furosemide
Reduces fluid retention,
swelling, and high blood
pressure
When taking with aspirin,
can lead to high blood
levels of aspirin as it
competes for elimination
of urine
Can increase blood sugar,
uric acid, and decrease
electrolytes.
Zocor
Lowers cholesterol and
triglyceride levels
Decrease elimination of
the drugs effects
Fruit juices can cause
increased blood levels
Isosorbide mono
Dilutes blood vessels to
prevent angina
Can reduce blood pressure
to unhealthy level if
mixed with calcium
channel blockers
Effects of drug are
decreased with high
vitamin C intake
trazodone
Antidepressant
High blood pressure and
confusion can occur when
taken with MAO
inhibitors
Drug absorption is
increased with food intake
Aspirin
Inhibits platelet
aggregation, reduces risk
of MI
Monitor amount taken
when being taken with
other drugs, can interfere
negatively
GI bleeding and iron
deficiency can occur with
prolonged use
Sodium bicarbonate
Inhibits production of acid
in the stomach
Can cause increase in
blood concentration when
taken with prilosec
Can cause sodium or
magnesium toxicity
NPH insulin/regular
insulin
Provides energy through
increasing the use of
glucose in blood
Don’t take with alcohol,
MAO inhibitors, beta
blockers, aspirin, or
steroids
Eat regular meals
Multivitamin
Helps with nutrient
deficiencies
Can affect or be affected
by other drugs
Can lead to nutrient
overload/toxicity
(http://www.medicinenet.com)
19. Identify all drug-drug interactions and then identify any drug-nutrient interactions for the
medications.
a. Answered in chart above. Many of the potential drug-drug and drug-nutrient reactions
could affect individuals in negative ways. It is crucial that individuals taking this many
medications at a time be aware of the the potential side affects that may occur.
20. What medications are the most likely to have contributed to the abnormal lab values and this
this diagnosis? Why?
a. The medications most likely to have contributed to the abnormal lab values and this
diagnosis are aspirin and sodium bicarbonate. When taken with as many other
medications as it currently is, aspirin can have negative effects on the body when
interacting with other medications. It will be competing for urine excretion with
Furosemide, and therefore leave extra aspirin in the blood and affect blood pressure.
Also, taking sodium bicarbonate can increase the base bicarbonate in the blood and
therefore cause higher pH values and lead to metabolic alkalosis.
21. What does the HbA1c measure? What can this value tell you about Mr. Kaufman’s overall
control over his diabetes?
a. The HbA1c measures your blood sugar control over the last three months. Mr.
Kaufman’s HbA1c measures 8.2%, when the normal value is between 3.9-5.2%. This
value shows he has not been taking good control over his blood sugar in the last three
months.
("Lab values explained:," 2012)
22. From the information gathered within the clinical domain, list possible nutrition problems
using the diagnostic term.
a. NC-2.1: Impaired nutrient utilization
NC-2.2: Altered nutrition-related laboratory values (osmolality, glucose, BUN,
Creatinine)
NC-3.3: Overweight/obesity
(http://www.adancm.com/vault/IDNT%20e3%20NDTerms-NCM.pdf)
23. List possible behavioral-environmental nutrition problems.
a. One problem could be the fact that Mr. Kaufman’s daughter does not know all the
medications he takes. It would be helpful for her and Mr. Kaufman to be educated on
the medications he is taking and how/when it would be best for him to take each
medication to avoid any negative drug-drug or drug-nutrient reactions. Mr. Kaufman’s
daughter makes most of his meals, and these meals are typically healthy, which is
good. However, it may help Mr. Kaufman to be more educated on how to make
healthier meals when he is required to make them himself.
24. Select two high priority nutrition problems and complete PES statements for each.
a. PES 1: Excessive energy intake related to obesity diagnosis as evidenced by 32.7
kg/m^2 BMI and usual intake.
PES 2: Lack of nutritional knowledge related to type 2 DM as evidenced by increased
blood glucose and HbA1c levels.
25. For each of the PES statements that you have written, establish an ideal goal (based on the
signs and symptoms) and an appropriate intervention (based on the etiology).
a. An ideal goal for the first PES statement would be to decrease his total energy intake to
lose some weight, which will also help him lower his BMI and blood pressure. He eats
a lot meat, which is good protein, but depending on the type of meat, it adds a lot of
extra fat and calories that he doesn’t need. There are other, more healthful foods he can
get extra protein from, such as nuts and legumes, that can also provide a number of
other important nutrients he may be lacking in.
An ideal goal for the second PES statement would be to educate Mr. Kaufman on how
he can better control his type 2 DM through nutrition therapy.
26. Would you make diabetes education a priority in your nutrition counseling for Mr. Kaufman?
What methods might you use to help maximize his glucose control? How would you assess
the patient’s and daughter’s readiness for change?
a. Mr. Kaufman has had type 2 DM for the past 15 years and it still unable to keep it
under healthy/proper control. Therefore, I think diabetes education would definitely be
a priority in my nutrition counseling. His nutrition history states he attended some
diabetic classes in the past, so he may know a brief overview, but he clearly doesn’t
completely understand how important it is to have control over his diabetes. Educating
Mr. Kaufman on what foods he can eat, when he should eat, and how they will effect
his glucose levels would be very beneficial. He also may not fully understand his
glucose regulator, so educating him on that would also be helpful. Mr. Kaufman’s
daughter shows a readiness to change. She has already helped him lose weight by
providing him with healthier meals. Her readiness to change will be very helpful in
making Mr. Kaufman more ready to change. I think Mr. Kaufman is ready to change,
and will be more likely to change now that he has had this hospital visit. I think as he
progresses through the nutrition therapy, he will be happy he’s learning how to control
his diabetes and manage his weight. Following a proper nutrition regimen will help
him live longer than he would without making any changes.
References
1. Haijar, E., Cafiero, A., & Hanion, J. (2007, December 05). Polypharmacy in elderly patients.
Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/18179993
2. Dube, I. (2009, December 7). Nutrition and supplements to reduce side effects in myositis.
Retrieved from http://www.hss.edu/conditions_nutrition-supplements-reduce-medication-sideeffects-myositis.asp
3. Good, C. B. (2002). Polypharmacy in elderly patients with diabetes. Diabetes Spectrum, 15(4),
240-248. Retrieved from http://spectrum.diabetesjournals.org/content/15/4/240.full
4. Epsy, M. (2012). Nutritional needs of the elderly. Retrieved from
http://www.healthguidance.org/entry/6267/1/Nutritional-Needs-of-the-Elderly.html
5. (n.d.). Retrieved from www.medicinenet.com
6. Langan, M. (2010, December 13). Aging changes in the kidneys. Retrieved from
http://www.nlm.nih.gov/medlineplus/ency/article/004010.htm
7. Pervin, L. (2008, February). Polypharmacy and aging: Is there cause for concern?. Retrieved
from http://www.rehabnurse.org/pdf/GeriatricsPolypharmacy.pdf
8. Halls, S. (2008, May 24). Body mass index charts of men. Retrieved from
http://www.halls.md/body-mass-index/mens.htm
9. Chernoff, R. (2008). Geriatric nutrition: The health professional's handbook. Jones and
Bartlett Learning. Retrieved from http://books.google.com/books?id=yq1bMzEfBbQC
10.
Kerstetter, J., Rodriguez, N., Insogna, K., & Gaffney-Stomberg, E. (2009, June 05).
Increasing dietary protein requirements in elderly people for optimal muslce and bone health.
Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/19460090
11.
Terms and definitions in pharmacology. (2011, April 25). Retrieved from
http://www.nursingprogramguide.com/nursing-program/terms-definitions-in-pharmacology/
12.
Lab values explained: Measures of kidney function. (2012). Retrieved from
http://lifeoptions.org/kidneyinfo/labvalues.php
13.
Austin, R. (2006). Polypharmacy as a risk factor in the treatment of type 2 diabetes.
Diabetes spectrum, 19(1), 13-16. Retrieved from
http://spectrum.diabetesjournals.org/content/19/1/13.full