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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