Nutrition Interventions in the anorexic Geriatric Patient Agenda Defining Geriatrics Physiologic Changes of Aging Psychological Changes with Aging Medical Nutrition Therapy of the Malnourished Geriatric Patient ID: 489629
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Slide1
By: Nicole Greene
Nutrition Interventions in the anorexic Geriatric PatientSlide2
Agenda
Defining Geriatrics
Physiologic Changes of Aging
Psychological Changes with AgingMedical Nutrition Therapy of the Malnourished Geriatric PatientPresentation of M.C.Critical CommentsSummaryQuestionsReferencesSlide3
Introduction
Aging
can’t be prevented
Malnutrition In the elderly often overlookedHow does physiologic, mental, and psychological changes affect nutrition in the elderly population?How can an early nutrition intervention
improve
quality of
life?Slide4
Defining Geriatrics
Greek
origin
Geron– elderIatros- healer Sub-specialty of internal and family medicine focused on prevention
and treatment of diseases and disabilities in the elderly
M
any countries have accepted the age of 65 as the definition of “
elderly” Slide5
Geriatric populationSlide6
Physiologic Changes associated with Aging
Different than treating a mid aged adult
Problems arise from choices made in their history
Changes can be summarized into several categories relating to the organ systems they compromise Every patient unique and may be experiencing different problems Slide7
Bone, Muscle, and Joint Issues in the ElderlySlide8
Cardiovascular conditions in Geriatric patients
Atrial Fibrillation
Hypertension
Coronary Artery DiseaseMyocardial InfarctionCongestive Heart FailureValvular DiseaseSlide9
Respiratory conditions in the elderly
Decreased
e
lastinDecreased vital capacityDecrease # of alveoliDecrease # of celiaSlide10
GI Symptoms in the elderly
Decrease in saliva production
Esophageal dysfunction
Atrophic gastritisAchlorhydriaDecreased liver metabolismDecreased absorption-lactose, calcium, ironSlide11
Changes in the elderly’s urinary system
V
ascular
blood flow to the kidneys decreases Nephrons decreaseDecreased tissue massBladder wall become less elastic Slide12
Changes in the Elderly’s Nervous System
Central processing of eye is decreased
Hearing losses
Slowing down of thought and memoryDEMENTIA IS NOT A NORMAL PROCESS OF AGINGSlide13
Changes in the Elderly’s Immune System Slide14
Psychological aspects of aging
Psychological, biological, environmental, and genetic factors all contribute to depression
Depression last longer in the elderly and increases the risk of death from illness Slide15
Malnutrition
Malnutrition
Increased morbidity and mortality in elderly
Lack of protein, energy, and other nutrients causes adverse effects on tissue form, composition, function, or clinical outcome The ADA/A.S.P.E.N. has developed criteria to diagnose malnutrition in adults
Serum proteins such as albumin and
prealbumin
are not included as defining characteristics of malnutritionSlide16
Diagnostic Tool to identify malnutrition
Moderate
Malnutrition
Severe Malnutrition
Moderate Malnutrition
Severe Malnutrition
Moderate Malnutrition
Severe Malnutrition
Food and Nutrient
Intake
< 75% of est.
energy requirement for > 7 d
ays
≤ 50% of est.
energy requirement for ≥ 5 days
< 75% of est.
energy requirement for ≥ 1 m
≤ 75% of est. energy requirement for ≥ 1 m
< 75% of est.
energy requirement for ≥ 3 m
≤ 50% of est.
energy requirement for 1 ≥ m
Interpretation of Weight Loss
1-2%: 1
wk
5%: 1 m
7.5%: 3 m
>2%: 1
wk
>5%: 1 m
>7.5%: 3 m
5%: 1 m
7.5%: 3 m
10%: 6 m20%: 1 yr >5%: 1 m>7.5%: 3 m>10%: 6 m>20%: 1 yr >5%: 1 m>7.5%: 3 m>10%: 6 m>20%: 1 yr>5%: 1 m>7.5%: 3 m>10%: 6 m>20%: 1 yr
Clinical CharachteristicMalnutrition in the context to acute illness or injury Malnutrition in the context of chronic illness Malnutrition in the context of social or environmental circumstances Slide17
Causes of Malnutrition in The geriatric population
Poor appetite
Chronic illness
Multiple medicationsCognitive declinePhysiologic weaknessOral healthDysphagiaDiarrhea or constipationEconomic hardshipSlide18
Consequences of malnutrition
M
orbidity
and mortality Greater risk for infections Cachexia Failure to thrive D
elayed
wound healing
I
mpaired
respiratory function
M
uscle
weakness
D
epression Slide19
Assessing the Malnourished Geriatric Patient
Physical signs
Muscle wasting
Temporal wastingPoor skin integrityDelayed healingSubcutaneous fat lossHair lossSlide20
Assessing the Malnourished Geriatric Patient
Body Mass Index
BMI
Interpretation
<15
Severely Underweight
<18.4
Underweight
18.5-24.9
Normal
25-29.9
Overweight
30-34.9
Obesity Grade I
35-39.9
Obesity Grade II
>40
Obesity Grade III
23-27
Normal for Elderly (65 and older)Slide21
Assessing the Malnourished Geriatric Patient
Interpretation of % Weight Change
Time
(%) Significant
wt
loss
(%) Severe
wt
loss
1 week
1-2
>2
1 month
5
>5
3 months
7.5
>7.5
6 months
10
>10
Unlimited time
10-20
>20Slide22
Assessing the Malnourished Geriatric Patient
FAILURE TO THRIVE
S
yndrome manifested by weight loss greater than 5 percent of baseline, decreased appetite, poor nutrition, and inactivityFour syndromes are prevalent and predictive of adverse outcomes in patients with FTT:Impaired physical functionMalnutritionDepression
Cognitive impairmentSlide23
Clinical Manifestations of
Refeeding
syndrome
Hypophosphatemia
Hypokalemia
Hypomagnesemia
Vitamin/Thiamine Deficiency
Sodium Retention
hypoxia
Nausea/Vomiting
Weakness
Encephalopathy
Fluid overload
Impaired cardiac function
Paralysis
Muscle Twitching
Lactic Acidosis
Pulmonary Edema
Respiratory failure
Muscle Necrosis
Anorexia
Death
Weakness
Alterations in myocardial contraction
Nausea
Vomiting
Diarrhea
Cardiac
Decompensation
Confusion
Electrocardiograph changes
Electrocardiograph changes
Restlessness
Cardiac Arrhythmias
Cardiac Arrhythmias
Seizures
Sudden Death
Seizures
Coma
weakness
ComaDeathRespiratory compromiseDeathSlide24
Estimating Nutritional Needs in the malnourished geriatric Patient
Caloric Needs
Weight based calculations
use actual weight for normal and underweight individuals
BMI
Interpretation
Kcal/KG
<15
Severely Underweight
35-40
<18.4
Underweight
30-35
18.5-24.9
Normal
25-30
25-29.9
Overweight
20-25
>30
Obesity
15-20
23-27
Normal for Elderly
22-28Slide25
Estimating Nutritional Needs in the malnourished geriatric Patient
Caloric
Needs
The Academy suggests a dietary prescription of 130% of the REE, but should be avoided when the patient is at risk for refeeding syndrome Penn State equation or Ireton Jones for critically illSlide26
Estimating Nutritional Needs in the malnourished geriatric Patient
Protein Needs:
Nourished
0.8-1.0 g/kg
Malnourished
1.2-2.0 g/kg
*Wounds and different disease states also may increase or decrease protein needsSlide27
Estimating Nutritional Needs for
Refeeding
syndrome
Start low and go slowProtein should not exceed 1-1.5 gm/kg of normal weight in the early stages of refeedingCalories: 20-25 kcal/kg actual body weightIf feeding
Parenterally
: CHO load start with 2 mg/kg/minute- prevents gluconeogenesis and minimizes insulin secretion
Restrict fluids to avoid edema
MONITOR LABS: ESPECIALLY PHOSPHORUS, POTASSIUM, AND MAGNESIUMSlide28
Methods of feeding the malnourished geriatric patient
Oral Feeding
Liberalizing the diet
Add High Calorie/High protein supplementsEnteral NutritionCan’t be fed orally or can’t meet needs orallyParenteral NutritionS
hould
only be initiated when medically necessary Slide29
Other Interventions
Possible medication changes
Remeron
Appetite stimulantsSlide30
Evaluating Feeding Success in the Malnourished Geriatric Patient
Weight gain (not in fluid)
Healing wounds
Nitrogen balanceA positive nitrogen balance suggest that nutrition intake is adequate to promote anabolism and preserve lean muscle massNegative nitrogen balance is when nitrogen excretion exceeds intake, reflecting muscle deterioration Slide31
Presentation of Patient: MC
68
-year-old widowed Caucasian
femaleTransferred from Lions Gate Nursing Home for SOB and tachycardiaThe patient apparently was not eating at all and is eating less than 5% of her diet report from Lions Gate Nursing HomeWeight is only 55 poundsThe patient was admitted here for psych evaluation for commitment and inpatient
treatmentSlide32
Initial Nutrition assessment (4/18/12)
Physician and RN consult, Calorie Count Consult
Diagnosis:
COPD Anorexia TachycardiaHx: COPD FTT
Cachexia
Kyphoscoliosis
Osteoporosis
H
ypokalemia
D
epression
Gait InstabilitySlide33
Food/Nutrition History
Transferred from Lyons Gate Nursing home
AAOx3
PO ~5% per nursing recordsPer H&P: Pt. refuses to eat, hides food, and throws up after mealsCalorie count initiated todayPt. likes ensure and needs soft foodNoted poor intake x 7 years since husbands death (weight was 126#)
Per noted record: weight stable at 75# in July 2011
? At risk for
refeeding
Current Diet Order:
General Diet +Ensure TID+ Ensure pudding BID, RN to watch pt. eat meals
Does not meet needs: pt. needs softSlide34
Labs:
Lab Value
Normal Range
Current Value
Nutritional Significance
Hemoglobin
12.0-16.0 g/
dL
12.3
-
Hematocrit
34.9-44.9%
36.2
-
Sodium
133-145
mmol
/L
139
-
Potassium
3.3-5.1
mmol
/L
3.4
-
BUN
6-20 mg/
dL
6
-
Creatinine
0.40-1.10 mg/
dL
<0.30 L
Muscle injury/ decreased muscle mass, low protein diet
Glucose
80-115 mg/
dL
67 L
Missed meals
Calcium8.8-10.0 mg/dL8.2 LHypoalbuminemia, deficiency, low Vit. D, malnutrition, osteoporosisPhosphorus2.7-4.5 ml/dL2.3 LmalnutritionMagnesium1.6-2.6 ml/dL1.6-
Albumin3.5-5.3 g/dL3.1 LInflammation, malnutritionPrealbumin17-35 mg/dL10.7 LMalnutrition, infectionsProtein5.9-8.3 g/dL5.2 L
Malnutrition, malabsorptionSlide35
Medications
Medication
Use
Protonix
GERD
Prednisone
Inflammation
Heparin
Prevent blood clots
Remeron
Depression/Appetite
Stimulant
Oscal
/
Vit
D 500-200
Osteoporosis
K-
Dur
Prevent Hypokalemia
Marinol
Appetite Stimulant
Ventolin
COPDSlide36
Anthropometrics:
Height
5’0
Weight
55
lb
or 25 kg
UBW
75
lb
or 34 kg (July 2011 or 8 months ago)
% Weight Change
27% in 8 months
IBW
96-125
lb
or 44-57 kg
% IBW
57 %
BMI
10.7
Physical Exam findings:
-Multiple Stage I and II Pressure Ulcers- Wound care pending
-Temporal Wasting
-Poor Dentition
-Hair LossSlide37
Nutritional Needs
Calories
625 kcal
will increase needs once clear from refeedingBased on 25 kg weight25 kcal/kg
Protein
34-51 g
Based on 34 kg (UBW)
1-1.5 g/kg
Fluid
~1290 ml
B
ased on 43 kg (IBW)
30ml/kgSlide38
Nutritional
Diagnosis
Suboptimal oral food beverage intake related to disordered eating as evidenced by weight loss of 26% over 8 months (severe), anorexia secondary to depression, BMI: 10.7, 57% of IBW
Goal: PO intake >50% of each meal/supplements within 3 days (calorie count)Slide39
Monitoring and Evaluation:
High acuity
Weight
PO intake/ kcal countElectrolytes (Na, K, Mg, PO4)Skin/Wound Care-pendingPsych Consult- pendingIncreased needsSlide40
Nutrition Interventions
Nutrition Education:
Verbal needs for tolerating PO/Increased needs
Coordination of Other Care During Nutrition Care:RN, Physician, and Calorie Count at BedsideRecommend:Check CRP,
Folate
, B12,
Vit. D
Start MVI daily
Change diet to mechanical soft with ground meats
Pt. would benefit from PEG tube/encourage feeding tube and consider GI consult for placement
Monitor Electrolytes- may be at risk for
refeeding
Consider 1:1 for questionable purgingSlide41
Calorie Count Note (4/19/12)
PO intake poor secondary to eating disorder
Pt. PO 250 kcal, 7
gm proteinMinimal PO at breakfast and no PO at dinnerPt. reports no appetite, but may be agreeable to PEGPt. complains of early satietyRecommendations: As able, GI to F/U with pt. referring increased anxiety with PEG procedureSlide42
Update! (4/19/12)
Spoke with patient
now agreeable for PEG
Consulted GIWill await pulmonary clearanceRecommend: Once PEG placed, initiate Jevity 1.2 @ 20 ml/
hr
and increase by 10 ml q 4
hr
until at goal rate of 40 ml/
hr
x 12
hr
480 ml total volume
576 kcal
27 g Pro
687 ml total H20Slide43
Nutrition Follow up (4/21/12)
A
Pt. ordered clear liquid diet
Calorie count range: 200-500 kcal/dayPOD #1 S/P PEG placedJevity 1.2 @ 10ml @present (goal is 40 ml x 12hr/day with AF)Pt. AAOx3 in good spiritsPOC: rehab@ D/COnce PEG feeds tolerated at goal 40mlx12
hr
(576 kcal, 27
gm
pro, 687 ml H2O), will progress
or change feeds to bolus. No new lab dataSlide44
Nutrition Follow up
Continued (
4/21/12)
DSuboptimal EN related to goal not yet reached as evidenced by EN @ 10 ml/hr (goal is 40 ml/hr x 12 hr)Goal: EN to meet estimated needs within 48 hours/ PO feeds for supplemental
I
Closely monitor electrolytes
Progress PO diet to mechanical soft with ensure BID
Oral care/ HOB
Jevity
1.2 @ goal 40 ml/
hr
x 12
hr
/day with AFSlide45
Nutrition Follow up Continued (4/21/12)
M/E: High Acuity
PO intake
ElectrolytesEN toleranceS/S of aspirationWound HealingSlide46
Nutrition Follow Up (4/24/12)
A:
Diet: mechanical soft general diet+ ensure TID+ ensure pudding BID
Jevity 1.2 @ goal rate of 40 ml/hr x12 hr via PEG Oral PO 0% per RN flow and pt. reportEN feeds well tolerated
Would benefit from increased needs with stable electrolytesSlide47
Nutrition Follow up Continued (4/
24/
12)
Estimated needs:875-1000 kcal35-40 kcal/kgBased on 25 kg weight66-88 g pro1.5-2.0 g pro
Based on IBW
1275 ml H2O
Based on IBW
~30 ml/kgSlide48
Nutrition Follow up Continued (4/24/12)
Additional
Medications
Milk of MagnesiaSenokotZofranLabs
67
L
132
L
3.5
93
L
33
H
12
<0.30
LSlide49
Nutrition Follow up Continued (4/24/12)
D:
Increased nutrient needs related to protein/energy malnutrition as evidenced by muscle wasting and temporal wasting
Goal: pt. will meet estimated needs within 24 hoursI:Jevity 1.2 @ 60 ml/hr
x 12
hr
(7pm-7am) + 2 oz
liquid protein via PEG
Provides:
720 ml total volume
864 kcal + 120 (liquid pro) = 984 kcal
40
gm
pro + 30
gm
(liquid pro) = 70
gm
pro
Free H2O with AF: 806 mlSlide50
Nutrition Follow up Continued (4/24/12)
M/E
:
WeightElectrolytes, prealbumin EN toleranceSkin/Wound HealingIncreased needs with weight gainSlide51
Critical Comments:
Improvements
Diet would have overfed patient
Should have used actual body weight for protein/fluidNurse couldn’t watch patient eat trayMg and PO4 labs weren’t ordered PositivesCommunication between multidisciplinary team
Gaining patient’s trustSlide52
Summary:
Geriatric population rapidly growing
Physical and mental changes occur with aging which may lead to decreased intake
Multidisciplinary team must be proactive in identifying warning signs, preventing, and treating malnutrition MC example of malnourished geriatric patient3 weeks later, I went to visit MC and she had gained 8.8 pounds. MC was working with PT to walk with a walker, but oral intake was still minimalSlide53
Questions??Slide54
References
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