I HAVE FEEDING ISSUES! Mark Jackson MD CMD

Transcription

1 I HAVE FEEDING ISSUES! Mark Jackson MD CMD

2 OBJECTIVES Understand terminology of weight loss Understand definition of weight loss Recognize medical causes of weight loss Recognize risk/benefit of restricted and dysphagia diets Recognize role of tube feeding Recognize role of orixogenic medications

3 CHANGES IN BODY COMPOSITION WITH AGE Bone mass, lean mass, water content Total body fat, commonly with intra-abdominal fat stores Cannot generalize well-standardized nutrient requirements of young or middle-aged adults to older adults Dietary intake is affected by: Sense of smell Salt and sweet sensitivity

4

5 ENERGY REQUIREMENTS OF OLDER ADULTS Reduced basal metabolic rate (BMR) in older adults reflects loss of muscle mass BMR is the principal determinant of total energy expenditure Estimation of energy needs based on body weight: 25 to 30 kcal/kg/day

6 FLUID NEEDS OF OLDER ADULTS Decreased perception of thirst is associated with normal aging Also associated with normal aging: Decreased response to serum osmolarity Reduced ability to concentrate urine following fluid deprivation 30 ml/kg/day or 1 ml/kcal ingested 2015 JAMDA Review of 23 studies showed no conclusive methods to reduce dehydration risk

7 ANTHROPOMETRICS Includes measures of weight and height Body mass index (BMI) = weight in kg/height in m 2 Risk threshold for low BMI = 18.5 kg/m 2 Weight loss of 5% in 1 month or 10% in 6 months indicates nutritional risk and morbidity and predicts: Functional limitations Health care charges Need for hospitalization

8 BODY SIZE CLASSIFICATION Underweight BMI < 18.5 Normal BMI Overweight BMI Obesity BMI > 30.0 Extreme Obesity BMI > 40.0

9 NUTRITIONAL INTAKE Inadequate nutritional intake has been defined as average intake of food groups, nutrients, or energy 25% to 50% below a threshold level of the RDA Minimum Data Set uses different measure: intake of <75% of food provided triggers nutritional assessment in nursing homes 5% to 18% of nursing home residents do not meet standards for adequate nutritional intake

10 The loss of appetite, anorexia, is commonly observed in older persons and is associated with adverse outcomes. Appetite is associated with seeking food for physiological need, and is conditioned by sensory perception, visual stimuli, and both social and cultural factors. Appetite is distinct from hunger, which is the physiological drive to find food. Hunger often results in aggressive food-seeking and in ingestion of nutrients which would otherwise be revolting. Remarkably, hunger seems to be suppressed in acute illness and in endstage starvation even in the face of availability of food and weight loss. Dr. David Thomas

11 LABORATORY TESTS: ALBUMIN A risk indicator for morbidity and mortality Lacks sensitivity and specificity as a nutritional indicator The prognostic value of low albumin (<3.5 g/dl) is probably as a marker for injury, disease, or inflammation Prealbumin may better reflect short-term changes in protein status (because of shorter half-life) but has largely the same limitations as albumin No benefit

12 LABORATORY TESTS: SERUM CHOLESTEROL Acquired hypocholesterolemia (<160 mg/dl) is a nonspecific feature of poor health status that is independent of nutrient or energy intake May reflect a pro-inflammatory condition Community-dwelling older adults with both low albumin and low cholesterol have higher rates of morbidity and mortality than those with either low albumin or low cholesterol alone

13 RISK FACTORS FOR POOR NUTRITIONAL STATUS (1 OF 2) Alcohol or substance abuse Cognitive dysfunction Decreased exercise Depression, poor mental health Functional limitations, limited mobility, transportation Inadequate funds Limited education

14 RISK FACTORS FOR POOR NUTRITIONAL STATUS (2 OF 2) Medical problems, chronic diseases Medications Poor dentition Restricted diet, poor eating habits Social isolation

15 NUTRITION SYNDROMES: OBESITY BMI 30 kg/m 2 BMI may be lowest health risk Associated with hypertension, diabetes mellitus, cardiovascular disease, and osteoarthritis Adverse outcomes include impaired functional status, increased health care resource use, increased mortality Prevalence has increased in all age groups

16 TREATMENT OF OBESITY Diet Behavior modification Exercise For frail, obese older adults, emphasize preservation of strength and flexibility rather than weight reduction No studies have shown mortality benefit of weight loss

17 NUTRITION SYNDROMES: UNDERNUTRITION Loss of weight, compromised protein status, or both The nomenclature implies that these syndromes are distinct, but in practice they are difficult to distinguish, partly because they commonly overlap Inflammation permeates the syndromes of cachexia, protein energy undernutrition, sarcopenia, failure to thrive, and obesity An inflammatory continuum may be a more appropriate model Undernutrition and malnutrition are synonymous for medical purposes and coding

18 Poor nutritional status of patients is a marker of poor health, not poor intake.

19 DEFINITIONS Sarcopenia Age related loss of lean muscle mass and function Cachexia Disease related loss of muscle and fat Anorexia Loss of appetite Starvation Inadequate ingestion of calories

20 SARCOPENIA 1 OF 2 Age related decline in muscle mass due to disuse atrophy or hormonal deficiencies Hallmark is loss of muscle mass, not fat Overall weight may decrease minimally Occurs in obese patients

21 SARCOPENIA 2 OF 2 Age related loss of muscle mass and function is consistent at 1-2% per year after age 50 Occurs in sedentary & active aging adults Leads to diminished strength and exercise capacity Causes also include chronic disease, inflammation, insulin resistance & nutritional deficiencies

22 ANOREXIA Decrease in appetite Systemic inflammation suppresses appetite Acute illness paradoxically suppresses appetite

23 CACHEXIA Weight loss due to effects of disease Cytokine-associated wasting of protein and energy stores Lose equal amounts of fat and skeletal muscle Cytokines are related to inflammatory response/chronic disease Remarkably resistant to hyper-caloric feeding

24 INTERVENTION FOR SARCOPENIA Primary intervention is resistance exercise Progressive resistance training 2-3 times per week Improve physical function Reduces physical disability & muscle weakness Improve balance, gait speed, timed walk Improve timed get up & go, chair rise, stair climb Benefit extends to the very old

25 STARVATION Inadequate ingestion of calories Hallmark of starvation is rapid response to re-feeding

26 DEPRESSION Depression is the most common treatable cause of anorexia Accounts for up to 36% Dr. David Thomas

27 CAUSES OF INVOLUNTARY WEIGHT LOSS Inadequate availability (starvation) Decrease in appetite (anorexia) Disuse atrophy or hormonal deficiency (sarcopenia) Effects of disease (cachexia) Dr. David Thomas

28 DISEASES WITH ANOREXIA/CACHEXIA SYNDROME Cancer Heart Failure ESRD COPD End Stage Dementia RA Liver Disease Chronic infections/aids Dr. David Thomas

29 OTHER MEDICAL ISSUES Depression Xerostomia Hyperthyroidism Constipation Dental Issues

30 COMMON DRUGS THAT CAUSE ANOREXIA Amlodipine Ipratropium Paroxetine Cipro Iron Phenytoin Conjugated Estrogen Levothyroxine Potassium Digoxin Memantine Ranitidine Donepezil Metformin Risperidone Enalapril Narcotics Sertraline Famotidine Nifedipine Warfarin Fentanyl Nizatadine Furosemide Omeprazole

31 DIETARY ORDER: Diabetic, low salt, low fat, low residue, renal diet with 2 liter fluid restriction

32 PRESCRIBED DIETS Alterations of food consistency often reduce nutrient intake to undernourished levels and do little to prevent aspiration Food that is unpalatable secondary to restricted diets (low-fat, low salt, renal, diabetic, fluid restricted) may decrease intake Dr. David Thomas

33 PIONEER NETWORK NEW DINING PRACTICE STANDARDS SEPTEMBER 2011 Recommended 10 new dining standards Emphasis on: Individualized nutrition approach Diet liberalization Real food first Honoring choices

34 AMERICAN MEDICAL DIRECTORS ASSOCIATION The use of therapeutic diets, including low-salt, low-fat, and sugar-restricted diets, should be minimized in the LTC setting.

35 CENTERS FOR MEDICARE & MEDICAID SERVICES Liberalized diets should be the norm, restricted diets should be the exception. Generally weight stabilization and adequate nutrition are promoted by serving residents regular or minimally restricted diets.

36 PREVENTING UNDERNUTRITION Cater to patient s food preferences Avoid restrictive therapeutic diets unless clinical value is certain Enhance patient s preparedness for meal; provide assistance if needed Enhance comfort, taste, appearance of food Enhance social aspect; provide adequate time Address dental/oral complaints of chewing discomfort/dysfunction

37 DIETARY SUPPLEMENTS Often decrease food intake, but overall nutritional intake increases due to nutrient quality and supplement density Contain macro- and micronutrients Available in liquid and bar forms Most formulas provide calories/ml, and many are lactose- and gluten-free Obviates need for MVI Give with med passes, not meals Diabetic supplements do not lower HbAlc

38 DYSPHAGIA Swallowing difficulties Oropharyngeal Esophageal In ECF, 50-75% of residents will have dysphagia

39 COMPLICATIONS OF DYSPHAGIA Malnutrition Dehydration Aspiration pneumonia (55% is silent) Mealtime stress and anxiety for patient Embarrassment for patient 1/3 stop eating despite still being hungry

40 TREATMENT OF DYSPHAGIA - PHYSIOLOGIC Safe swallow techniques Head positioning Double or repeat swallow

41 TREATMENT OF DYSPHAGIA DIETARY MODIFICATION Altering solids Altering liquids Frazier Free Water Protocol

42 ALTERED DIET CONSISTENCIES SOLIDS Regular Cut up Chopped Ground Pureed LIQUIDS Unrestricted (thin) Nectar Honey Pudding

43 EVIDENCED BASED? A systematic review of studies of dysphagia secondary to stroke published by the Agency for Healthcare Research and Quality concluded that evidence was insufficient to recommend one type of swallowing study over another and that data correlating specific findings from any type of examination with clinically meaningful outcomes are lacking (SOE=C). AGS Geriatrics Review Syllabus 2013

44 COCHRANE ANALYSIS 2008 Review of Dysphagia in Chronic Muscle Disease The main treatment options for dysphagia are dietary manipulation (altering the consistency of food and adding supplements), adopting safe swallowing techniques, surgical interventions and feeding through the stomach (enteral feeding). No randomized controlled trials of the effectiveness of treatments for dysphagia in muscle disease were identified.

45 2013 AGS CHOOSING WISELY Don t insert PEG tubes in individuals with advanced dementia. Instead, offer oral assisted feedings.

46 TUBE FEEDING 1 OF 2 No studies demonstrate that feeding tubes reduce the occurrence of aspiration, but rather many studies identify feeding tubes as major risk factors for aspiration. There is little evidence to support use of feeding tubes in end-stage cancer, dementia or COPD.

47 TUBE FEEDING 2 OF 2 In demented persons, feeding tubes DO NOT improve survival, reduce aspiration, improve function, reduce pressure ulcers, or reduce mortality. Cochrane 2009 The only disease for which feeding tubes have been shown to be beneficial is esophageal obstruction.

48 COMPLICATIONS OF FEEDING TUBES 8%-30% experience complications Increased risk of aspiration pneumonia Metabolic disturbances Diarrhea Local cellulitis Behavioral issues

49 TUBE FEEDING AND SURVIVAL Mortality is high for PEG patients 24% dead in one month 63% dead in one year 81% dead in three years

50 Poor nutritional status of patients is a marker of poor health, not poor intake.

51 HAND FEEDING BENEFITS Perception that person is not starved Human, interactive care is direct and not merely symbolic Comfort is provided from the look, texture, and smells of food Patient controls the amount and rate of feeding

52 ORIXOGENICS=APPETITE STIMULANTS Antidepressants, e.g. mirtazapine Antihistamine, e.g. Cyproheptadine (Periactin) Cannabinoids Thalidomide TNF inhibitor Megestrol acetate (Megace) Anabolic steroids, including DHEA & HGH NO FDA APPROVAL FOR GERIATRIC ANOREXIA

53 MIRTAZAPINE (REMERON) Serotonin norepinephrine reuptake inhibitor Antagonizes 5HT3 receptor 7.5 mg 30 mg hs

54 CYPROHEPTADINE (PERIACTIN) Serotonin & histamine antagonist 2 mg-4 mg tid with meals May enhance appetite but without weight gain Potential for confusion in older adults SOE rating C

55 MEGESTROL ACETATE (MEGACE) Progestin 800 mg daily Appetite & weight improve Primarily fat Clinical benefits not demonstrated (SOE=A) Increased risk of DVT, fluid retention, edema, CHF May negate benefits of rehab on strength & function Beers Criteria inclusion 2012 $400/month

56 CANNABANOIDS Dronabinol (Marinol) mg bid before lunch & dinner Nabilone (Cesamet) Improve mood & appetite in cancer & AIDS, but without weight gain or functional improvement 10 mg bid = $1750/month

57 THALIDOMIDE Restricted distribution Tumor necrosis factor inhibitor Caused weight gain in AIDS

58 RECOMBINANT HUMAN GROWTH HORMONE Induces preferential usage of CHO and fats while preserving proteins & increasing muscle mass mg/kg/day IM divided in 3 doses Increase in strength & functional capacity depends on exercise Contraindicated with cancer Increased risk of hyperglycemia & fluid retention No studies have shown significant functional benefits Beers Criteria 2012

59 ANABOLIC STEROIDS Testosterone mg IM q 3 weeks or 5 mg patch/gel daily Modest increase in muscle mass & bone density No significant increase in strength, function or reduction in fractures Increased risk of cardiovascular events Concern re prostate cancer Includes DHEA, oxymetholone, oxandrolone Beers Criteria 2012

60 VITAMIN D SUPPLEMENTATION Vit D decreases chronic musculoskeletal pain, reduces falls, improves strength, and reduces mortality following fracture Vit D3 50,000 u po q wk X 8 wk, Then 2000 u qd or 50,000 u q month Shoot for level of Levels > 150 may cause hypercalcemia and hyperphosphatemia

61 VITAMINS: THE GOOD THE BAD AND THE UGLY JOHN MORLEY, JAMDA 2014 Antioxidants had 22.7% mortality vs. 10.2% in placebo Vitamin E, CoQ10, Alpha Lipoic Acid Replace B12 and Folate for documented deficiency Multivitamins not indicated Vitamin D 1000 IU daily is recommended

62 FISH OIL SUPPLEMENTS JAMA - August 27, 2014 Conclusion: Omega-3 polyunsaturated fatty acids can lower high plasma triglycerides, but they have not been shown to decrease the risk of pancreatitis. The results of recent studies do not offer any convincing evidence that fish oil supplements prevent cardiovascular disease.

63 CONCLUSION Understand terminology of weight loss Understand definition of weight loss Recognize medical causes of weight loss Recognize risk/benefit of restricted and dysphagia diets Recognize role of tube feeding Recognize role of orixogenic medications