Nutrition and Malnutrition in
the Elderly
Goals, Objectives, Standards



Goals
 Appreciate the scope of nutritional assessment and intervention
in the medical care of the elderly
Objectives
 Practice use of nutrition screens
 Practice implementation of nutritional interventions
 Code correctly for evaluation and treatment
Standards
 Use DETERMINE nutritional screen
 Use Mini Nutritional Assessment
 Compute Body Mass Index
 Compute Ideal Body Weight
 Compute Energy Needs
 Compute Protein Needs
Case Phase 1: Evaluation of Outpatient


82 yr female on a fixed income lives at home
alone and is dependant upon friends as for
transportation. She has HTN, CAD, CRF, and
OA all modestly controlled on HCTZ, ACE1,
TNG, beta-blocker, and acetaminophen. Her
chief complaint is having trouble dressing
herself secondary to L shoulder pain. You
note a 10 pound weight loss since her last
visit six months ago.
What do you do next?
Demographics

Malnutrition



Independent 0-6%
Skilled Care 2-27%
Hospital
10-30%, up to 75%

Stay is longer with more malnutrition
MACRONUTRIENTS I


Water

8 x 8 oz/d

30ml/kg/d or 1ml/kcal eaten
Carbohydrates 55-60% total kcal/d





½ carbs from whole grains
Proteins 1 to 1.5 gm/kg/d
Fats <30% total kcal/d
Cholesterol < 300 mg/d
Fiber > 4 gm/d
Macronutrients II

Electrolytes






Na <2300 mg/d (1 tsp), <1500 mg/d blacks
K K rich foods
, >4700 mg/d blacks
Mg
Calcium 1200 mg/d
Phosphorous 700 mg/d
Iron 25-40 mg/d
Micronutrients



Vitamins, Co-factors
Minerals
Trace Elements



Multivitamin
Multivitamin
Multivitamin
Anthropometrics I

Clinical

10 pound loss in six months or weight < 100 lbs



Relative Risk of Death 2.0
PPV of malnutrition = 0.99
Minimum Data Set


Weight loss >= 5% past month
Weight loss >= 10% past six months
Anthropometrics II

BMI : Body mass index = weight (kg) / height (m2)

Correlated to nutrition status, morbidity, mortality








18.4 and lower greater risk malnutrition and related diseases
30 and higher the greater risk for DM, CAD, HTN, OA, CA
National Practice Standard = Compute @ each office visit
Underweight
Normal weight
Overweight
Obesity
Extreme Obesity
<18.5
18.5-24.9
25-29.9
>= 30
>= 40
BMI Table http://www.nhlbi.nih.gov/guidelines/obesity/bmi_tbl2.htm
BMI
19
20
21
22
23
24
25
Height
26
27
28
29
30
31
32
33
34
35
Body Weight (pounds)
58
91
96
100
105
110
115
119
124
129
134
138
143
148
153
158
162
167
59
94
99
104
109
114
119
124
128
133
138
143
148
153
158
163
168
173
60
97
102
107
112
118
123
128
133
138
143
148
153
158
163
168
174
179
61
100
106
111
116
122
127
132
137
143
148
153
158
164
169
174
180
185
62
104
109
115
120
126
131
136
142
147
153
158
164
169
175
180
186
191
63
107
113
118
124
130
135
141
146
152
158
163
169
175
180
186
191
197
64
110
116
122
128
134
140
145
151
157
163
169
174
180
186
192
197
204
65
114
120
126
132
138
144
150
156
162
168
174
180
186
192
198
204
210
66
118
124
130
136
142
148
155
161
167
173
179
186
192
198
204
210
216
67
121
127
134
140
146
153
159
166
172
178
185
191
198
204
211
217
223
68
125
131
138
144
151
158
164
171
177
184
190
197
203
210
216
223
230
69
128
135
142
149
155
162
169
176
182
189
196
203
209
216
223
230
236
70
132
139
146
153
160
167
174
181
188
195
202
209
216
222
229
236
243
71
136
143
150
157
165
172
179
186
193
200
208
215
222
229
236
243
250
72
140
147
154
162
169
177
184
191
199
206
213
221
228
235
242
250
258
73
144
151
159
166
174
182
189
197
204
212
219
227
235
242
250
257
265
74
148
155
163
171
179
186
194
202
210
218
225
233
241
249
256
264
272
75
152
160
168
176
184
192
200
208
216
224
232
240
248
256
264
272
279
76
156
164
172
180
189
197
205
213
221
230
238
246
254
263
271
279
287
BMI: NIH Recommendations



Clinicians should measure BMI and offer obese
patients intensive counseling and behavioral
interventions.
The National Institutes of Health provides a BMI
calculator at www.nhlbisupport.com/bmi and a table
at www.nhlbi.nih.gov/guidelines/obesity/bmi_tbl.htm.
The Centers for Disease Control and Prevention
provides a BMI calculator at
www.cdc.gov/nccdphp/dnpa/bmi/calc-bmi.htm.
Anthropometrics III : Research tools







Skin fold and mid-arm circumference
Water Displacement
Bioelectrical Impedance
Dual Radiographic Absorptiometry
CT
MRI
Total Body 40K
Wasting and Cachexia

Wasting - Severe weight

loss and diminished
nutritional intake




Cachexia - Inflammatory
cytokine mediated wasting
Semistarvation
Reduced metabolic demand
Visceral protein sparing
Obvious weight loss







RA, CHF, COPD, HIV, Critical
care without nutritional support

Semistarvation overlap
Increased metabolic demand
Visceral protein wasting
ECF incr masks weight loss
Limited response to
antiinflammatory/anabolics
Nutritional intervention slows
semistarvation part
Marasmus, CA, HIV with opp
inf, critical care without
nutritional support, chronic
organ failure
Protein-Energy Undernutriton

Clinical wasting + albumin < 3.5 gm/dl






> 1/3 hospital
< 1/3 NH
< 10% independent
Big cachexia overlap
Nutrition support
Treat underlying disease
Failure to Thrive

Not a defined syndrome in the elderly
DETERMINE Screening Tool









D isease
E ating poorly
T ooth loss, mouth pain
E conomic hardship
R educed social contacts
M ultiple medications
I nvoluntary weight loss or gain
N eed for assistance in self-care
E lderly (age > 80)
DETERMINE Evaluation

Read the statements below. Circle the number in “YES” column for those that apply to you or
someone under your care. For each “YES” answer, score the number n the box. Total your
nutrition score.


I have an illness or condition that made me change the kind and/or amount of food I eat
I eat fewer than 2 meals a day
I eat few fruits or vegetables, or milk products
I have 3 or more drinks of beer, liquor, or wine almost every day
I have tooth or mouth problems that make it hard for me to eat
I don’t always have enough money to buy the food I need
I eat alone most of the time
I take three or more different prescribed or over-the-counter drugs a day
Without wanting to, I have lost or gained 10 pounds in the last 6 months
I am not always physically able to shop, cook, and /or feed myself

Note: Scoring: 0-2 = good, 3-5 = moderate nutritional risk, 6 or more = high nutritional risk








2
3
2
2
2
4
1
1
2
2
DETERMINE Your Nutritional Health Checklist. Nutrtion Screeining Initiative, a project of the American Academy of Family Physicians, the American Dietetic Association, and the
National Council on Aging, Inc., and funded in part by Ross Products Division,
Mini-Nutritional Assessment (MNA)

Two Part




3 min screen
8 min diagnostic
Validated against measurable standards
Inclusive, Plenary
MNA Part 1 Skill Session
MNA Part 2 Skill Session
MNA Study Results

Oral supplementation in skilled living elderly
with MNA 17-23.5 and < 17 with 1 can (400
kcal) significantly increased:




calorie intake
MNA score about 3 points
Weight
about 1.5 kg
Alzheimer’s

Supplementation at 2 kg weight loss stabilizes
weight loss compared to controls
Food Pyramids



MyPyramid.gov
Culturally distinct
More flexible
MyPyramid.gov







Grains – gold
Vegetables – green
Fruits – red
Oils – yellow
Milk – Blue
Meats + Beans – Purple
Discretionary Calories


< 200 to 300 kcal
Exercise

30, 60, 90 rule
Age Specific Recommendations

People over age 50.


Consume vitamin B12 in its crystalline form (i.e.,
fortified foods or supplements).
Older adults, people with dark skin, and
people exposed to insufficient ultraviolet band
radiation (i.e., sunlight).

Consume extra vitamin D from vitamin D-fortified
foods and/or supplement
Nutrient-Nutrient/Drug Interactions

Numerous

Ca, Mg, Fe
Phytins (in fiber)
Tannins (coffee, tea)





Bind drugs/nutrients
Bind drugs/nutrients
Bind drugs/nutrients
Drug-Nutrient Interactions I









Alcohol
Antacids
Antibiotics
Colchicine
Digoxin
Diuretics
Isoniazid
Levodopa
Laxatives









Zn, A, B1, B2, B6, B12, folate
B12, folate, Fe, kcal
K
B12
Zn, kcal
Zn, Mg, B6, K, Cu
B6, niacin
B6
Ca, A, B2, B12, D, E, K
Drug-Nutrient Interaction II








Lipid Binding Resins
Metformin
Mineral Oil
Phenytoin
Salicylates
SSRI
Theophylline
Trimethoprim








A, D, E, K
B12, kcal
A, D, E, K
D, folate
C, folate
Kcal
Kcal
folate
Nutrient Treatment of Disease





Ca and Vit D for osteoporosis
B6, B12 for homocysteinosis
Antioxidants CAD, Macular Degeneration
Vitamin E failed for AD
Watch for overdosing of vitamins!
Case Phase 2 – Outpatient Treatment

She responds to in-home physical therapy
after a steroid injection of her L shoulder. She
starts to eat breakfast and uses a supplement
when her appetite is poor. Meals on wheels
brings her one meal a day. She eats with a
friend who cooks every Tuesday at lunch.
She gains back 7 pounds.
Case Phase 2 : Hospital Evaluation


Your patient falls and breaks her left hip. She
survives a L total hip replacement, but
develops pyelonephritis with bacteremia at
the hospital. She is delirious. She loses 15
pounds.
What do you do now?
Nutrition Requirement Calculations 1

Estimated Energy Needs by Weight



25-30 kcal / kg body weight / day
Use 120% IBW for obese persons
Estimated Protein Needs by Weight



Protein = (0.8-1.5) gm / kg body weight / day
Use IBW for obese persons
May need to be higher (2.0-3.0) for stressed and
or very malnourished persons.
Nutrition Requirement Calculations 2

Harris-Benedict Basal Estimated Basal
Energy Expenditure (BEE)



Male BEE = 66 +(13.7 x weight in kg) + (5 x
height in cm) – (4.7 x age)
Female BEE = 665 +(9.6 x weight in kg) + (1.8 x
height in cm) – (4.7 x age)
Multiply by 1.00 (non-stressed) to 1.50 (stressed)
Laboratory Evaluation

Albumin < 3.8 g/dl




Prealbumin



Shorter half-life than albumin
No more predictive
Cholesterol < 160 mg/ml


Lacks sensitivity and specificity
May decline very slightly with age
Negative acute phase reactant
Indicates underlying serious disease in community, hospital
and NH patients
Total Lymphocyte Count < 2000 cells/microliter
Tube Feeding

3-7 days of 1-2 kcal/ml supplement


1500-2400 ml per day to achieve water,
protein, calorie goals





Convert to PEGE for “long term” use
Start full strength, increase rate
Measure residuals, convert to bolus feeds
Supplement enzymes
Treat diarrhea
Deal with aspiration
TPN


For non-functioning GI tract
No EMB studies in elders
Case Phase 2: Hospital Treatment


After pulling out her NG tube every shift for
24 hours, she is given TPN through her
central line. After 48 hours, she is dyspneic,
hypoxic, and edematous.
What do you do now?
Re-feeding Syndrome

Syndrome of





Most pronounced with parenteral nutrition




hypophosphatemia
hypomagnesemia
fluid retention
about 3 days into re-feeding
Occurs with oral re-feeding as well
More severe with worse malnutrition
Frequent subclinical presentation
Reduce re-feeding rate for three days to treat
Case Phase 3: Skilled Facility Evaluation

She recovers from bacteremia, and since she
cannot tolerate a rehab schedule due to
residual delirium and weakness is placed in
skilled care. While there, she does poorly in
PT/OT. Has restricted diet order for CHF. On
narcotics, anxiolytics. She is depressed,
constipated, requires 1-2 person assists for
ADL’s. She has no appetite.
Anorexia






Drugs
Anemia
Uremia
Liver Disease
Dry Mouth
Pain






Cancer
Inflammation
Psychiatric Illness
Bowel Disease
Constipation
Malnutrition
Anorexia : Appetite Stimulation









Food Appearance
Salt
Sugar
Social Contact
Feeding
Ambience
Familiarity
Drugs
Ghrelin, other hormones
Anorexia : Pharmacologic Support

Mirtazipine


Cannabis, Cannabinoids, Tetrahydrocannabinol and its derivatives








Probably risk of DVT is too high for routine use
Corticosteroids


Unsure, probably in depression
Estrogens/Progestins/Thalidomide


No therapeutic effect or use in medicine
Ritalin


probably works
Especially in cancer, hematologic, neurologic
Prokinetics
Cyproheptadine
Hydrazine sulphate – no utility
Dronabinol
Antiserotonergic drugs
Branched-chain amino acids, Eicosapentanoic acid
Melatonin
Sarcopenia of the Elderly

Age related loss of skeletal mass



Type I fibers spared
Type II loss of number and size
Questions:





Sedentary
Dietary
Hormonal
Neurologic
Sex hormonal
Case Phase 4

Recovers
ICD-9 Codes

Malnutrition
1st degree (mild)
2nd degree (moderate)
3rd degree (severe) (protein calorie)
From neglect
Causes problems for NH
263.1
263.0
262
995.84
Hypoalbuminemia / Hypoproteinemia
Protein Deficiency / Kwashiorkor
Marasmus
273.8
260
261
















Causes problems for NH
Senile Marsmus
Intestinal Marasmus
Lack of Food
Nutritional Deficiency, particular, specify
Undernourishment/Undernutrition
Weight loss (cause unknown)
Failure to thrive

Causes problems for NH
797
569.89
994.2
269.9
269.9
783.21
783.7
Treatment of Malnutrition


Ease dietary restrictions
Supplements




Foods
Enhanced Milk or Soy based products
Drugs
Supportive Therapies
Summary




Malnutrition is prevalent in the elderly
Reproducible assessment is available
Intervention prevents morbidity and mortality
Supplements have a role in therapy
Bibliography







Cobbs EL, Dithie EH, Murphy JB, eds. Geriatrics Review Syllabus: A Core Curriculum in Geriatrics Medicine. 5th
ed. Malden, MA: Blackwell Publishing for the American Geriatrics Society; 2002.
MyPyramid.gov United States Department of Agriculture
Screening for Obesity in Adults. What's New from the USPSTF? AHRQ Publication No. 04-IP002, December
2003. Agency for Healthcare Research and Quality, Rockville, MD.
http://www.ahrq.gov/clinic/3rduspstf/obesity/obeswh.htm
http://www.mna-elderly.com/
Cornali, Cristina, Franzoni, Simone, Frisoni, Giovanni B. & Trabucchi, Marco (2005)
ANOREXIA AS AN INDEPENDENT PREDICTOR OF MORTALITY.
Journal of the American Geriatrics Society 53 (2), 354-355.
doi: 10.1111/
j.1532-5415.2005.53126_4.x
Visvanathan, Renuka, Macintosh, Caroline, Callary, Mandy, Penhall, Robert, Horowitz, Michael & Chapman, Ian (2003)
The Nutritional Status of 250 Older Australian Recipients of Domiciliary Care Services and Its Association with Outcomes at 12 Months.
Journal of the American Geriatrics Society 51 (7), 1007-1011.
doi: 10.1046/
j.1365-2389.2003.51317.x
http://www.nhlbi.nih.gov/guidelines/obesity/bmi_tbl2.htm
Journal of the American Geriatrics Society
Volume 52 Issue 10 Page 1702 - October 2004
doi:10.1111/j.1532-5415.2004.52464.x
Persson, Margareta D., Brismar, Kerstin E., Katzarski, Krassimir S., Nordenström, Jörgen & Cederholm, Tommy E. (2002) Nutritional Status Using
Mini Nutritional Assessment and Subjective Global Assessment Predict Mortality in Geriatric Patients. Journal of the American Geriatrics
Society 50 (12), 1996-2002.
doi: 10.1046/j.1532-5415.2002.50611.x
Bibliography

Hematol Oncol Clin North Am. 2002 Jun;16(3):589-617.Related Articles, Links

Update on anorexia and cachexia.
Strasser F, Bruera ED.
Department of Palliative Care and Rehabilitation Medicine, MD Anderson Cancer Center, 1515 Holcombe Boulevard, Box 0008, Houston, TX 77030, USA
Cancer Surv. 1994;21:99-115.
Anorexia and cachexia in advanced cancer patients.
Vigano A, Watanabe S, Bruera E.
Palliative Care Program, Edmonton General Hospital, Canada
.
CA Cancer J Clin. 2002 Mar-Apr;52(2):72-91.
Cancer anorexia-cachexia syndrome: current issues in research and management.
Inui A.
http://www.bccancer.bc.ca/PPI/UnconventionalTherapies/HydrazineSulfateHydrazineSulphate.htm