Download Undernutrition and Weight Loss in the Elderly

UNDERNUTRITION AND
WEIGHT LOSS IN THE
ELDERLY
NAUSHIRA PANDYA M.D.,C.M.D.
Chair and Associate Professor
Department of Geriatrics
Director, Geriatric Education Center, NSU COM
CECILIA ROKUSEK Ed.D., R.D.
Professor of Family Medicine and Public Health
Executive Director, Geriatric Education Center, NSU COM
The scope of the problem
Mode of living
Free-living
Sec, UK
Prevalence(%) References
5
Dept of Health and Social
7
Dept of Health and Social
5
2
1-4
39
59
50
22
30-60
10-85
Blondel-Cynober et al.
Lowink et al.
Cederholm et al.
Cederholm et al.
Rapin et al.
Alix.
Volkert et al.
Rudman et al.
Kerstetter et al.
Sec, UK
Hospital
Nursing home
52
3000
51
2500
50
2000
49
(Kcal)
3500
1500
48
1000
47
500
46
0
45
20-29
30-39
40-49
50-59
Age(y)
60-69
70-79
>80
(% of energy)
Change in food intake over the life spanNHANES III
Kcal Men
Kcal Women
Carbs
NHANES 111 DATA
4% of persons between 60-69 yr were unable to
prepare their meals or walk around
23% of persons over 80 yr were unable to
prepare their meals and 17% were unable to
walk
GFR < 30ml/min/1.72m2 major risk factor for
malnutrition in older adults
30-40% of patients on dialysis were malnourished
Marwick C. JAMA 1997;227
Normal aging changes, physical,
psychological and social precipitants
Anorexia
Weight loss
Malnutrition
Depression
Cognitive dysfunction
Social withdrawal
Isolation
Giving up
DEATH
Egbert
Barriers to adequate nutritional management of
older patients by physicians
Inadequate training in recognizing protein calorie
undernutrition
Unawareness that protein calorie undernutrition
may be the presenting feature of many treatable
diseases in the elderly
Unawareness of currently available treatment
options
Morley
Conditions associated with protein-energy
undernutrition in the elderly
Immune deficiency, increased infection, pneumonia
Pressure ulcers
Poor wound healing
Anemia
Falls
Cognitive deficits, increased delirium
Osteopenia, hip fractures
Altered drug metabolism
Sarcopenia, weakness, fatigue
Orthostatic hypotension and dehydration
Non-thyroidal illness
Decreased maximal breathing capacity
Decreased cardiac output
Predictors of nutritional disorders and disability
Katz ADL index score
Serum albumin level
Patient’s current weight as percentage of usual weight
Number of prescribed medications taken
Presence of renal disease (BUN level > 30)
Individual’s income
Presence of one or more decubiti (grade II or higher)
Dysphagia
Mid-arm muscle circumference
Sullivan DH
Nutrition and immunity in the elderly
Infections are more common in the undernourished - especially
pulmonary
Cell-mediated immunity and delayed hypersensitivity declines
Total lymphocyte count ↓ (< 800/mm3 reflects undernutrition)
T cell proliferation ↓
B lymphocyte proliferation È
Cytokine release ↓ (IL2 and IL1) - fever often absent, and inflammatory
syndromes have prolonged evolution periods
È CD4:CD8 ratio in undernourished patients who are HIV Micronutrient supplementation has been showed to restore T cell
deficiency (zinc-thymulin, Vit E -?antioxidant)
Usual aging is associated with decrease in skeletal and
visceral lean body mass (LBM), bone density, total
body water, and increase in total fat
SARCOPENIA wasting of
skeletal muscle
LBM declines 19% in men
and 12% in women (2575y)
Due to aging, inactivity,
malnutrition, catabolic
diseases (CHF, COPD,
cancer, hyperthyroidism)
CACHEXIA is loss of
both muscle and fat
Not physiologic
Occurs in malignancies
and HIV disease
Systemic inflammatory
response
Outcomes of Severe Weight Loss in Older
Persons
Increased hospitalization
Increased length of hospital stay
Increased hospital costs
Delayed recovery from surgery
Increased mortality (weight loss in 6 mths in NH pts
associated with 2 fold increase in likelihood of death- Yamashita et al.
2002)
Increased NH placement in older women (BMI <
21.4 Kg/m2 )
The assessment
Case 1
A 73 yr old woman is noted to have a 10 lb
involuntary weight loss at her annual physical
Food just does not appeal to her and she can’t
be bothered with meals; she lives alone
She has HTN, osteoarthritis, glaucoma, and
T2 diabetes
Medications: captopril, metformin, naproxen
Exam: unkempt, apathetic, R knee effusion
What further questions would you ask?
What would you look for in the
physical exam?
Important points in the history
Anorexia?
Early satiety?
Nausea?
Change in bowel habits?
Fatigue or apathy?
Memory loss?
Depression?
Food availability? Poverty?
Social history
Physical signs of Undernutrition
Loss of subcutaneous fat
- interossei and palmar creases
- loss of fullness in arms, chest wall
- squared-off appearance of shoulders
Muscle wasting (sarcopenia)
- loss of tone and bulk in quadriceps, deltoids
- reduced strength
Edema of ankles, sacrum, and even ascites
- absence of weight loss misleading
Dysphoria, decreased cognition
Poor wound healing, pressure ulcers
Parameters Used in Identifying Undernutrition
Body weight loss (>5% in 30 days or 10% in 180 days)
Body mass index < 19 kg/m2 (may be spuriously elevated)
Severe if BMI < 16
Dietary food intake of less than 75% of meals for 3 days
Serum albumin value of less than 3.5 or 3.0 g/dl (decreases
by 0.8 per decade after age 60) Influenced by
posture, CHF, dialysis, cytokines, dialysis, nephrosis,
paraproteinemias
Serum cholesterol value of less than 160 mg/dl (occurs late,
limited use for screening)
Associated with hospitalizations, LOS, complications, mortality
Screening and Assessments Tools
SCALES - outpatient screening tool
DETERMINE - a low specificity tool, increases public
awareness, and easily performed by the patient
- developed by the Nutrition Screening Initiative (AAFP,
Am Diet.Assoc, Nat Council of the Aging)
- Level I Screen separates those who need evaluation and
intervention from those who need other medical and
community services
- Level II Screen by physician or other primary provider
(includes anthropometrics, labs, social and functional
testing
MNA - Mini Nutritional Assessment.
Malnutrition Inflammation Score (dialysis patients)
SCALES Protocol for evaluating risk of malnutrition in the
elderly (scores > 3 indicates patient at clear risk) Morley 1991
Item evaluated
Criterion for 1 point
Criterion for 2 points
Sadness GDS
10-14
> 15
Cholesterol
< 160 mg/dl
--
Albumin
3.5 - 4.0 g/dl
< 3.5 g/dl
Loss of weight
(MAC 1 month)
1 kg (or ¼” in MAC 3 kg (or 1/2”)
in 6 months)
Eating problems
assistance
Patient needs
--
Shopping and food Patient needs
prep problems
assistance
--
Why does caloric intake
decrease in the elderly?
ALTERATIONS IN THE HEDONIC QUALITIES OF
FOOD WITH AGING
Food enjoyment depends on taste, odor, temperature,
texture, masticatory sounds, all of which are altered
Smell declines progressively; hence monotonous diets
Alzheimer’s, Parkinsonism, laryngectomy, B12
deficiency, hypothyroidism, RF, cirrhosis, diltiazem,
streptomycin
Reduction in sensory-specific satiety
Increase in taste thresholds; sweet least affected modality;
flavor enhanced foods better consumed
Difficulty recognizing taste mixtures
Social isolation
Anorexia of aging- Physiological reduction in
food intake with advanced age
Food intake is lower in healthy older persons, especially of
fat rather than carbohydrates
È BMR due to loss of muscle
Immobility
Greater satiation after a standard meal than younger
people
Reduced fundic nitric oxide leads to a decrease in adaptive
relaxation and earlier satiation (È by leptin, Ç by NPY)
Opiod feeding drive (for fats) is less efficient
Refeeding can reset appetite
Elderly demented patients often eat enough for their diminished energy
requirements
Hoffer, L J. BMJ 2006;333:1214-1215
Copyright ©2006 BMJ Publishing Group Ltd.
Some
postulated
factors
involved in
the
pathogenesis
of
physiologic
anorexia
ÀTaste and smell
OVARIES
Àestrogen
ADIPOCYTES
¿leptin
CENTRAL NERVOUS
SYSTEM
ÀDynorphin
ÀNeuropeptide Y
¿CART
TESTIS
Àtestosterone
ANOREXIA
CYTOKINES
TNF α
Interleukin-1
Interleukin-6
STOMACH
Àadaptive relaxn
¿ Antral stretch
DUODENUM
¿cholecystokinin
Àmuscle mass
WEIGHT
LOSS
Neurotransmitters and Hormones Involved in the
Control of Food Intake (ÈÇ changes with aging)
Stimulate
Inhibit
Peripheral motilin
Cholecystokinin
Glucagon-like peptide 1
ÇAmylin
ghrelin
Hormones Thyroid
È Testosterone
Central
Dynorphin
neuropeptide Y
orexinA
Melanin-conc H
Cortisol
Progestagens
Dopamine
Norepi
Histamine
ÈNO
Leptin (males only)
cytokines
È Estrogen (females
only)
CRH
Serotonin
Isatin
Dopamine
Ç CART
Stress,
Infection
Burns, Trauma
Increase in
Glucocorticoids
Mineralocorticoids
ADH
Decreased IGF1
Gluconeogenesis
Protein catabolism
Lipolysis
Fluid, electrolyte
shifts
Inc macrophage
proliferation
Inc release of IL1, TNF
Colony stim factor
Gamma interferon
Protein Energy
Malnutrition
Hypoalbuminemia
Liver dysfunction
Decreased host defenses
Inc requirement for
Cals + protein
Pathophysiology of protein-energy malnutrition.
Inc ESR
Leukocytosis
Anorexia
Protein
catabolism
Weight loss
“Meals on Wheels”: causes of weight loss
M: medications (dig, theophylline, fluoxetine)
E: emotional (depression)
A: alcohol, anorexia tardive, or elder abuse
L: late life paranoia
S: swallowing problems (dysphagia, candidiasis, webs)
O: oral or dental problems (xerostomia)
N: nosocomial infections (TB, C.Diff, H Pylori)
W: wandering, dementia problems
H: hyperthyroidism, hypercalcemia, hypoadrenalism
E: enteric problems (gluten entropathy, pancreatic insufficiency)
E: eating problems
L: low salt, low fat diets (ADA and other therapeutic diets)
S: shopping and food preparation problems
Morley
Causes of weight loss - MEDICAL
Dysgeusia (antibiotics, captopril, tegretol, allopurinol, L
dopa, lithium, baclofen, antihistamines, Vit A, zinc
deficiency)
Anorexia (Addison’s disease, dyspepsia*,H. Pylori
infection, hypercalcemia)
Oral and swallowing problems, dry mouth, poorly fitting
dentures, web stricture, esophageal candidiasis
Malabsorption (Celiac disease, intestinal ischemia)
Increased metabolism (hyperthyroidism,
pheochromocytoma)
Metabolic (diabetes, hepatic, renal, cardiac failure)
Chronic infections, TB
Mixed causes (cancer*, Parkinsonism, COPD, cardiac
cachexia)
Causes of weight loss - SOCIAL
Poverty, fixed income
Functional impairment limiting ADL’S, dependancy
Social Isolation
Elder abuse, caregiver fatigue
Poor nutritional knowledge
Finicky eaters
Alcohol
Institutional factors- inadequate assistance
Ethnic food preferences
Monotony of institutionalized food
Causes of weight loss -PSYCHOLOGIC
Dementia
Depression*
Bereavement
Alcoholism
Late-life mania or paranoia
Anorexia tardive or nervosa
Sociopathy (loss of locus of control)
Excessive burden of life
Phobias (cholesterol or choking)
Globus hystericus
Drug Therapy That May Contribute to
Nutritional Disorders
Cardiac glycosides (digoxin)
Diuretics
Anti-inflammatory drugs
Antacids (overuse)
Psychotropic drugs
Antidepressants (SSRI’s)
Antineoplastic drugs
Anticonvulsants
Phenothiazines
Oral hypoglycemics
Anti-parkinsonian
Anticholinergic
Alibhai, CMAJ. 2005
March
So What is Frailty?
A physiologic state of increase vulnerability to
stressors that results from decreased
physiologic reserves and even dysregulation,
of multiple physiologic systems
Evidence indicates that Frailty may be a result
of alterations in metabolic activity, that then
leads to derangement of normal physiology
Cytokine over expression
Hormonal imbalances
Frailty vs. Disability vs. Co morbidity
Fried, LP, et al. Journal of Gerontology 2001 M146 – M156
Consequences of Frailty
Disability
Difficulty with Activities of Daily living
Dependency
Falls
Need for Long – Term Care
Mortality
Phenotype of Frailty
SHRINKING
Unintentional weight loss
Sarcopenia
WEAKNESS
POOR ENDURANCE & ENERGY
SLOWNESS
LOW ACTIVITY
FRAILTY: 3 or more criteria
PREFRAILTY: 1 or 2 criteria
Fried, LP, et al. Journal of Gerontology 2001 M146 – M156
Frailty Syndrome Criteria
WEAKNESS
Grip strength in the lowest 20% at baseline; adjust
for gender
and BMI
MEN
Cutoff for Grip Strength
(Kg) criterion for frailty
BMI </= 24
BMI 24.1 – 26
BMI 26.1 – 28
BMI > 28
<29
<30
<30
<32
WOMEN
Cutoff for Grip Strength
(Kg) criterion for frailty
BMI </= 23
BMI 23.1 – 26
BMI 26.1 – 29
BMI > 29
<17
<17.3
<18
<21
Aging & Frailty
Revised schematic of homeostenosis: The older person employs or consumes physiologic reserves just to
maintain homeostasis, and therefore there are fewer reserves available for meeting new challenges
Copyright © 2003 Spring-Verlag New York, Inc. All rights reserved.
Cycle of Frailty
Cytokine Over Expression
IL-6, IL-1, TNF-a, IL-2, Hsp70
atherosclerosis
anemia
PAD, CAD,
Cerebrovascular
disease
Falls, Heart
failure…
Osteoporosis or
osteopenia
Cognitive decline
Dementia
Sarcopenia
Fractures
Falls
Impairments in Function, mobility, and/or endurance
FRAILTY
Cytokines & Frailty
Interleukin -6 (IL-6), TNF-alpha, Heat Shock protein
70:
Found to be elevated in older adults who complain of
fatigue and found to have poor mobility and poor muscle
endurance
Bautmans et al. JAGS. 56:3, pgs 389-396
IL-6 found to be elevated in older people with
cachexia
Hubbard et al. JAGS. 56:2, pgs 279-284
That subclinical anemia may be a related to chronic
inflammatory state marked by serum IL-6 elevation
Leng et al. JAGS. 50:7, pgs 1268-1271
Hormones & Frailty
Hormone
Deficient states may lead to the
following
Growth Hormone, IGF-1
Sarcopenia, Osteoporosis
Testosterone
Cognitive decline, Depression,
Osteoporosis
Estrogen *
Osteoporosis, Cognitive decline
Vitamin D
Osteoporosis, Sarcopenia, poor
mobility
* Replacement not recommended
Prevention of Frailty
Address Nutrition, Function & Co-morbidities
Diabetes Control
Stroke prevention
CAD, PAD treatment
Fall prevention, Physical therapy interventions
Exercise
Nutritional evaluations
Immunizations, Vaccinations
F. R. A. I. L. T. Y.
Food intake:
Maintain nutrition, protein intake, fiber intake
In between meal supplements
Appetite enhancers such as marinol and megestrol
Supplement for any nutritional deficiencies
B12, B6, Folate
F. R. A. I. L. T. Y.
Resistance exercise 3x/ week
Resistance with weights or bands builds muscles
and helps reduce joint stiffness and pain
Exercise has been shown to
Increase muscle strength
Increase muscle size
Increase gait velocity
Increase mobility
Case 2
A 68 yr old retired accountant is noted to have
a 12 lb weight loss at his clinic visit for a
diabetic foot ulcer, complicated by chronic
osteomyelitis
Meal intake reduced by 50%, but he has
adequate resources and lives with his wife
who is his caregiver. More fatigued and slow.
Exam: CBG 209, cheerful, sarcopenia in UE
and LE, draining heel wound,
How would you manage
this patients weight loss?
Treatment Strategies
Identify cause/causes and initiate targeted dental,
medical, psychological, social, or community intervention
Thorough evaluation of all prescription and OTC
medications
Nutrition counseling of patient and caregivers
Nutritional supplementation
Increased staff at mealtimes, food presentation, taste
enhancement, change meal times (not 8-5 PM)
Orexigenic drugs
Useful non-invasive screening tests
Complete blood count
Liver function tests (including alkaline
phosphatase and bilirubin), measurement of LDH
Chest radiography
Patients with iron-deficiency anemia or
symptoms likely to originate in the
gastrointestinal tract, and patients with elevated
liver enzyme levels on initial screening, should
undergo
either endoscopy or UGI series
or abdominal ultrasound
Identify and treat
the cause
Despite therapy no
increase in weight
No cause identified or
no treatable condition
NUTRITIONAL SUPPORT
Frequent small meals high in
protein and fat
Supplements, night snacks
PHYSICAL THERAPY
Exercise
OCCUPATIONAL
THERAPY
? ANABOLIC AGENTS
No weight
gain
Improved prognosis
+ quality of life
Weight gain
Consider enteral
Hyperalimentation
No terminal illlness
Pt + family consent
Poor prognosis
A rational approach to the treatment of weight loss in the elderly.
Algorithm for managing weight loss in outpatients
NO
DEHYDRATION?
Treat
YES
DECREASED FOOD AVAILABILITY?
YES
NO
APPETITE PROBLEM?
YES
NO
DELIRIUM?
Treat
YES
YES
Treat
MALABSORPTION?
YES
NO
NO
DEPRESSION?
Treat
Refer to social
worker
HYPERMETABOLISM?
NO
YES
CONSIDER OREXIGENICS
LOOK FOR TREATABLE CAUSES
? Malignancy ?other
Treat
Nutritional supplementation
Palatable meals high in protein and fats
Give priority to ethnic food preferences
Nutritional supplements as meal replacements or late
night snacks
Liquid energy supplements to swallow medications
(Medpass 2.0 can treat weight loss in nursing homes)
Begin aggressive efforts to assure adequate intake 48h
after acute hospital admission
Enteral tube feeding (NG or J tube) has fewer problems,
is more cost-effective and efficient than parenteral
feeding (TPN)
Peripheral parenteral nutrition (PPN) for short term
support (10% dextrose, amino acids and intralipid)
Calculating enteral feeding requirements
Protein*
Clinical condition
Amount
Maintenance
1.2 – 1.5 g/kg/day
Stress
1.5 – 2.0 g/kg/day
Maintenance
25 – 30 kcal/kg/day
Stress
30 – 40 kcal/kg/day
Sepsis
40 – 50 kcal/kg/day
*
Calories#
Free water
30 – 35 ml/kg/day
*Use IBW in obese persons
# Use 120% IBW in obese persons
Pharmacological treatment of weight loss
Small gain in weight without evidence of
decreased morbidity and mortality or
improved function and quality of life
Orexigenic (appetite-stimulating) and
anabolic medications
Only 4 have been studied in randomized trials
Orexigenic Drugs
AGENT
MECHANISM OF ACTION
Megestrol acetate
Progestagen/anticytokine
Dronabinol
Cannabinoid
Cyproheptadine
Antiserotonin
Anabolic steroids (Oxandrolone) Mainly on muscle
Growth Hormone
Central
Corticosteroids
Central
Metoclopromide
Increased gastric emptying
Antidepressants
Treat depression
(Mirtizapine)
5HT1 agonist, 5HT2 antagonist
MEGESTEROL ACETATE
Progestational effect antagonizes estrogen (which ↓ food
intake)
Main effect is antagonism of cytokine production (TNFα,
IL6)
Increases appetite, weight, well being and fat mass
Useful in older persons with anorexia caused by cytokine
excess (cancer, AIDS, P ulcers, arthritis, recurrent infections)
May cause DVT or adrenal suppression
Orexigenic drugs and Their Side Effects
Cyproheptadine
Testosterone (gel,patch,
injection)
Oxymethalone/oxandrolone
nandrolone
Growth hormone
Megestrol acetate
Dronabinol
Delirium
Increased Hct
Not with prostate Ca
Fluid retention
Skin irritation
Liver dysfunction
Renal failure
Carpal tunnel syndrome
Arthralgias
Increased death
Deep vein thrombosis
hypoadrenalism
Delirium
Morley. Clin Geriatr Med Nov 2002
Addressing
Weight Loss Issues
in the Elderly
Voluntary Weight Loss
Dietary modification required because
of OW/OB
Weight modification because of diagnosed
medical conditions
Personal feelings of OW
Involuntary Weight Loss
Depression (> in LTCF)
Cancer
Cardiac disorder
Alcoholism
Benign gastrointestinal diseases
Medication
Polypharmacy
Cognitive impairment
Nutrition Assessment is Key
Physiologic Anorexia of Aging
By the age of 65 years,
approximately 50 percent of
Americans have lost teeth!
Weight loss should NEVER
be considered as part of
the normal aging process.
Nutritional Assessment
Anthropometric measures
General physical assessment
Dietary assessment
Self assessment
Medication review
Environmental scan
Treatment
Team approach
Use of flavor enhancers
Small, frequent meals
Exercise
Medications
Feeding tubes
Voluntary Weight Loss Issues
Planning
Exercise
↓ fat usually preferred
Small, frequent meals/snacks
!!! REMEMBER !!!
Eating food is one of life’s
greatest pleasures as we mature!
QUESTIONS?
Naushira Pandya, MD, CMD
[email protected]
Cecilia Rokusek, EdD, RD
[email protected]