Geriatric Approach to Nutrition & Weight Loss in Older Adults - PowerPoint Presentation

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Geriatric Approach to Nutrition & Weight Loss in Older Adults

Monica Esquivel, RD, PhDAssistant ProfessorUH Manoa

Aida Wen, MD

Associate Professor

JABSOM

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Learning Objectives

Understand the Nutritional Needs of Older Adults Be able to recognize and evaluate undernutritionKnow what resources are available to manage undernutrition in a way that maximizes quality of life.

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Prevalence of Malnutrition in OA

Present in about 13% of older outpatients

25-50% of hospitalized OA

> 50% of nursing home residents

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AGS GEM Toolkit:

Nutrition & Weight Loss

(You can download the PDF on the Resources tab on the GWEP Website)

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Age-Associated Changes

Lower bone mass, lean mass, and water content; more fat mass

Reduced basal metabolic rate due to loss of lean body mass

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Older Adult Food Pyramid Guide:

www.choosemyplate.gov

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Fluid Needs of Older Adults

Decreased thirst perception, response to changes in serum osmolality, and ability to concentrate urine

Fluid needs are about 30 mL/kg/day or 1mL/kcal ingested.

Ex: 120 lb (60kg) person x 30mL/kg = 1800 mL/ day.Dehydration is the most common fluid or electrolyte disturbance in older adults.Including dairy drinks will also provide protein and calcium

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Healthy Fats

Fats are important to keep body warm & help the body absorb fat-soluble vitamins

Unsaturated Fats are healthier: Nuts, olive oil, fish, avocados

20-35% calories from Fat

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Carbohydrates

Carbohydrates are important for energy

Sugars- fruits and vegetables

Starches- wheat, bread, pasta, rice, potatoes

45-65% calories from carbs

About 130 gm of carbohydrates per day

Reduced Basal Metabolic Rate (BMR) in older adults reflects loss of lean body mass, including muscle mass

Energy needs is based on body weight

25 to 30 kcal/kg/day= Thus for a 60 kg person = 1800 kcal

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Protein Needs

Protein 0.8 g/kg/day or 10-35% of total energy (or 1.5 g/kg/d if stress/injury)

A 60 kg person would need 50 g protein/ day.

140 gm = 1/3

lb

16 gm protein

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Fiber Requirements

30g for men

21 g for womenFIBER SUPPLEMENTS for CONSTIPATION (insoluble)

BenefiberPsylliumCitrucel

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Micronutrients: Calcium, Vit D, Vit B12

Drink 3 cups of fat-free or low-fat milk throughout the day. If you cannot tolerate milk try small amounts of yogurt, butter milk, hard cheese or lactose-free foods.

Calcium 1000 mg/ day

Consume foods fortified with vitamin B12, such as fortified cereals

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Nutritional Screening

Loss of 10

lbs

(4.5 kg) of usual body weight over 6-12 months.

Predicts functional limitation

Need for hospitalization

Healthcare costs

Anthropometrics: BMI = weight in kg/ height in m

2

Interpreted in context of their lifelong weight history

BMI ≤ 17 kg/m

2

Inadequate intake is 25-50% below recommended daily intake

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Nutrition Screening: Tools

By Patients:

Simplified Mini-Nutritional Assessment

By Professionals:

DETERMINE Checklist

Mini-Nutritional Assessment (MNA

)

Identifies those at

RISK

for malnutrition, not diagnosis

https://www.mna-elderly.com/default.html

(See Resources tab)

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Medical History

Chronic diseases (CHF, COPD, CKD, Chronic inflammation, GI problems, neurodegenerative diseases)

Restricted diet from chronic disease

Polypharmacy- Adverse Drug Events

Cancer

Depression

Cognitive dysfunction

Dysphagia

Dental problems

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Social History

Problems obtaining food

Money

Transportation

Functional limitations

Ability to open packages and prepare foods

Low Education/ Poor eating habits

Social isolation

Decreased activity/ mobility

Alcohol or Substance use disorder

Mental Health

Neglect or self-neglect (consider involving APS)

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Medications: Drug-Nutrient Interactions

ANOREXIA

DigoxinPhenytoinCholinesterase Inhibitors (e.g. Aricept)SSRI antidepressantsProton Pump InhibitorsCalcium Channel BlockersREDUCED NUTRIENT AVAILABLITY

Alcohol (Zn, A, B1, B2, B6, B12, folate)Antacids, H2-Blockers, PPI (B12, Folate, Iron)Antibiotics (K)Colchicine (B12)Diuretics (Zn, Mg, B6, K, Cu)Isoniazid (B6)Laxatives (Ca, ADEK, B12)Levodopa (B6)

CONSTIPATION

Anticholinergic drugs (H2 blockers, antihistamines, TCA)

Opioids

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Physical Examination

BMI

Look for skeletal muscle wasting (sunken temples, protruding collar bones and ribs, sunken hand muscles)

Nonhealing skin wounds

Pressure ulcers

Functional decline

Clues for underlying causes (dry mouth, dentition, neurological,

etc

)

Note any edema (may mask weight loss)

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Nutrition Screening: Lab tests

Albumin <3.5 g/dL

Associated with increased LOS, complications, readmissions, and mortality in the hospital setting. (lacks sensitivity and specificity for malnutrition)

Prealbumin <16 mg/dL

Associated with malnutrition, not reliable in context of inflammatory conditions.

Reflects short term changes in protein status (half-life 2-3 days)

Low Cholesterol < 160mg/dL,

Nonspecific feature of poor health status, independent of nutrient or energy intake

May also check Vit D levels: 25(OH) D

Repletion reduces falls, improv physical performance, bone healing and response to bisphosphonates.

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Management Principles

Address underlying cause

Vitamin D (800 IU daily) AND Calcium (1000 mg daily) supplementation

Specific supplementation with other vitamins, minerals and antioxidants is not necessary

High calorie supplements? May improve weight, but no evidence that it changes outcomes.

FOCUS and promote Quality of Life, Mood, and Functional status.

FOCUS on

Q

UALITY

OF LIFE

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Nonpharmacologic Management

Cater to food preferencesAttend to consistency, color, texture, temperature of foodProvide hand and mouth care as neededProvide feeding assistanceAvoid excessive salt and sugarUse herbs and spicesGive adequate time for meal

Address cultural needsAvoid therapeutic dietsComfortable settingIncrease SocializationAvoid hard to open packages

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Pharmacologic Management (AVOID)

Avoid using prescription appetite stimulants

All medications are off-label

No evidence of improvement in long-term survival or Quality of Life

Mirtazapine

Dronabinol

On Beers List with Strong Warning:

Cyproheptadine

Megastrol

(See Resources tab)

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Problems…

>20% weight loss usually represents protein calorie malnutrition

20% weight loss is associated with impaired physiologic function and immunity (cell mediated immunity and humoral immunity)

Excess loss of lean body mass is associated with poor wound healing, infections, Pressure ulcers, depression, functional ability and mortality

https://www.youtube.com/watch?v=qWCLOUPJs7M

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Choose Hand Feeding

Not Tube Feeding

DYSPHAGIA VIDEO: https://www.youtube.com/watch?v=RxikqBCycgI&feature=youtu.be

(See Resources tab)