Managing Nutrition and Unintended Weight Loss

Transcription

1 Managing Nutrition and Unintended Weight Loss Kathleen Niedert, PhD, RD, CSG, FADA, LNHA 2018 Spring Conference & Exhibitor Show May 2-3, 2018 OBJECTIVES Define the three main categories and three primary etiologies of unintended weight loss (UWL) Describe challenges that can inhibit adequate nutrition status in older adults Discuss clinical consequences of weight loss Explain how to develop interventions that are consistent with the individual s wishes and in line with the new RoPs 1

2 Categories of Unintended Weight Loss Physiological Pressure injuries/nonhealing wounds Loss of strength leading to falls Hip fractures Dehydration Infection Immune dysfunction Anemia Loss of teeth Lower nutrient absorption Changes in the sense of taste and smell Categories of Unintended Weight Loss Psychological Depression Dementia Anxiety Anorexia nervosa Bereavement 2

3 Categories of Unintended Weight Loss Social Poverty Isolation Needing help with meals Statistics concerning UWL No obvious cause in 1 out of 4 older adults with UWL Found in 13% of ambulatory older adults Identified in 50-60% of those in nursing facilities One of most challenging clinical problems facing adults 65 and older 3

4 Statistics concerning UWL Malignacy (19%-36%) Unknown (6%-28%) Psychiatric (9%-24%) Nonmalignant GI disease (9%- 19%) Endocrine (4%-11%) Cardiopulmonary (9%-10%) Alcohol-related disease (8%) Infectious disease (4%-8%) Neurologic (7%) Rheumatic disease (7%) Renal disease (4%) Systemic inflammatory disorders (4%) Three primary etiologies of UWL Starvation Most extreme form of marasmus Consequence of partial or total lack of essential nutrients for a long time Reversed solely by the replenishment of nutrients Sarcopenia Loss of skeletal muscle mass and quality associated with functional decline Includes sarcopenic obesity Primary interventions include resistance training and increased protein intake Cachexia Severe wasting that goes along with disease states (cancer) Is the clinical consequences of a chronic, systemic inflammatory response characterized by loss of skeletal muscle with or without loss of fat mass 4

5 Medication Adverse Effects that May Lead to Weight Loss Altered taste or smell: ACE inhibitors, ATB, anticholinergics, antihistamines, calcium channel bockers, levodopa, propranolol, spironolatctone Anorexia: ATB, anticonvulsants, antipsychotics, benzodiazepines, digoxin, levodopa, metformin, neuroleptics, opiates, SSRIs, theophylline Dry mouth: Anticholinergics, antihistamines, loop diuretics Dysphagia: Bisphosphonates, doxycycline, NSAID, potassium Nausea/Vomiting: ATB, bisphosphonates, digoxin, dopamine, metformin, SSRIs, statins, tricyclic antipdepressants Symptoms Often Seen in Those with UWL Fever, fatigue Dysphagia, oral/gum problems Dyspnea, exertional fatigue Indigestion, abdominal pain, change in stool pattern, early satiety 5

6 Definitions that may cause confusion Avoidable Unavoidable Insidious Usual body weight Avoidable Weight Loss Avoidable weight loss means that the individual did not maintain acceptable parameters of nutritional status and that the facility did not do one or more of the following: Evaluate the individual s clinical condition and nutritional risk factors Define and implement interventions that are consistent with the individual s needs, goals, and recognized standards of practice Monitor and evaluate the impact of the interventions Revise the intervention, as appropriate. 6

7 Unavoidable Weight Loss Unavoidable weight loss means that the individual did not maintain acceptable parameters of nutritional status even though the facility had: Evaluated the individual s clinical condition and nutritional risk factors Defined and implemented interventions that are consistent with resident needs, goals, and recognized standards of practice Monitored and evaluated the impact of the interventions Revised the approaches as appropriate. Insidious weight loss Insidious weight loss refers to a gradual, unintended, progressive weight loss over time. Often as little as 2-5 pounds per month that doesn t trigger weight loss under the CMS definition of significant weight loss In the Iowa Women s Health Study, one or more episodes of unintentional weight loss of more than 20 pounds during adulthood was associated with a 46%-57% higher rate of death. 7

8 Usual Body Weight Usual body weight is the individual s usual weight through adult life or a stable weight over time. Does not mean you can continually change the resident s UBW to suit your circumstances Challenges that can inhibit adequate nutrition status Advanced dementia Cancer Chronic infections or inflammatory conditions COPD Depression Uncontrolled diabetes Hyperthyroidism Malabsorption syndromes (eg, gluten enteropathy) Oral disease including poor dentition Polypharmacy (including anorexigenic medications) Swallowing disorders Therapeutic diets 8

9 Challenges that can inhibit adequate nutrition status CNA s that consistently overestimate intake of foods and fluids Not consistently being offered foods and fluids between meals nor being provided appropriate assistance to encourage consumption Need to be provided in a group with staff available to talk with them as well as assist those that need help Not enough staff in the dining room to adequately assist residents Staff triage residents at mealtimes with those with the most functionally and cognitively impaired getting the most help Need as many as possible trained as Feeding Assistants office staff, housekeepers, social services, activities staff Evaluating Status Through Nutrition Assessment Food/nutrition related history Food and nutrient intake Loss of appetite Eating dependency Swallowing problems Food and nutrition administration Meal and snack patterns Biochemical data, medical tests and procedures Altered nutrition-related lab data (NOTE: There is NOT a single lab value that can describe nutrition status) Swallowing evaluation 9

10 Evaluating Status Through Nutrition Assessment Anthropometric measurements Height, weight, weight history, usual weight BMI Nutrition-focused physical findings Overall appearance Muscle and fat wasting Oral cavity, skin condition, vital signs Client history Age, race/ethnicity, gender Medical, surgical, and social history Presence of infections, pressure ulcers, cognitive decline, depression History of supplemental usage or enteral/parenteral feeding What Are Our Nutrition Options? Increase energy intake Low energy intake consistently associated with frailty Increase protein intake Most studies suggest higher intake of protein is inversely associated with frailty Remember only 30 grams of protein synthesized at a time Examine potential micronutrient deficiencies (Vitamins A, E, and D) Low levels associated with increased risk of frailty Studies suggest increased need for vitamin B6, vitamin D, and calcium At risk for B12 deficiency although DRI is not higher 10

11 Food-Nutrient Delivery Considerations FOOD FIRST!!!! Individualize diets Remember that swallowing abnormalities are common but do NOT necessarily require modified diet or fluid textures, especially if these restrictions adversely affect food and fluid intake Supplements ONLY when truly needed and then 1 hour before or after meals. Food-Nutrient Delivery Considerations Consider a multivitamin and mineral supplement or specific nutrient supplements as determined during assessment Develop feeding strategies Adaptive equipment Alternate flavors and textures; food preferences/favorite foods Consistent caregiver Different dining environments Nutrition support ONLY when consistent with Advance Directives Don t forget physical exercise specifically weight-resistant bands and weights 11

12 Environmental Considerations (Resident Centered) Involve the resident in menu planning to satisfy their personal preferences Individualize the person s meal plan Allow the individual to make choices of what to eat, where to eat and what time to eat Provide participation in creative dining styles: restaurant, buffet, open dining, 24 hour room service Environmental Considerations (Resident Centered) Provide a dining ambiance that is well lighted, clean, and safe Allow the person to eat at his or her own pace with dining assistance and cueing available to those requiring it Invite families to bring in the individual s favorite foods and dine with the resident Provide snacks and beverages 24 hours a day stock the areas with both healthy snacks and those most often requested Serve items that are colorful, tasty, and palatable Make sure staff conversations involve the resident NOT OTHER CNAs 12

13 Use of Appetite Stimulants Review of literature highlights a relative lack of efficacy in their use May have an increased risk of adverse events when using them No drug has received FDA approval for geriatric anorexia Most physicians feel should be considered ONLY after all standard food and nutrition interventions have failed Ethical Issues Resident has right to refused nutrition and hydration as medical treatment When in end stages of a terminal disease, including dementia, more invasive and advanced interventions may not be appropriate There may be a time when UWL cannot be halted and is an expected part of the disease progression. 13

14 What is the prognosis for those with UWL? UWL of more than 4% in a year appears to be an independent predictor of increased mortality Those who lost 5% or more within one month were 4.6 times more likely to die within one year THE IMPACT ON LIFE EXPECTANCY OF TREATING THE WEIGHT LOSS REMAINS UNCLEAR WITH BOTH NUTRITIONAL AND PHARMACOLOGIC INTERVENTIONS FOUND TO BE OF LIMITED VALUE BUT AS A HEALTHCARE PROFESSIONAL YOU MUST TRY. TAKE AWAY TODAY Unintended weight loss in the older adult is a harmful occurrence that should be prevent if at all possible 14