Malnutrition & the older patient

James T. Birch, Jr., MD, MSPHAssistant Clinical Professor – Dept. of Family Medicine

Division of Geriatric MedicineLandon Center on Aging

KU Medical CenterFebruary 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 - 3Quality indicators for Malnutrition ACOVE-3 indicators are comprised of IF-THEN-

BECAUSE 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 protein-energy 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 drug-nutrient 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 StatusAlcohol or substance abuse Limited mobility, transportation

Cognitive dysfunction Medical problems, chronic diseases

Decreased exercise Medications

Depression, poor mental health Poor dentition

Functional limitations Restricted diet, poor eating habits

Inadequate funds Social isolation

Limited education (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 SSRI’s / 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 Reduced Nutrient Availability Alcohol Zinc, vitamins A, B1, B2, B6, folate, vitamin B12

Antacids Vitamin B12, folate, iron, total kcal

Antibiotics, broad-spectrum Vitamin K

Digoxin Zinc, total kcal (via anorexia)

Diuretics Zinc, magnesium, vitamin B6, potassium, copper

Laxatives Calcium, vitamins A, B2, B12, D, E, K

Lipid-binding resins Vitamins A, D, E, K

Metformin Vitamin B12, total kcal

Phenytoin/Salicylates Vitamin D, folate/Vitamin C, folate

SSRIs Total kcal (via anorexia)

Trimethoprim 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 EquationMale 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/dayRestriction of these amounts may be indicated in renal or hepatic insufficiency

Estimation of fiber: (complex carbohydrates are the preferred fiber source)Men: 30 gm/dayWomen: 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 well-nourished 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 pointsModerate nutritional risk 3-5 pointsHigh 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 don’t 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 Nestlé Research Center, in collaboration with hospital clinicians

Nutritional Screening and Assessment The MNA obviates the need for blood tests

to screen and monitor a patient’s 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 ClassificationBody Size Body Mass Index (kg/m²)

Underweight < 18.5

Normal weight 18.5-24.9

Overweight 25-29.9

Obesity ≥ 30

Extreme Obesity ≥ 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 Alzheimer’s 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 age-related 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 we’ve 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 month’s 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