POM III - Nutrition and FTT - Exam 2

Failure to Thrive

Syndrome of: weight loss, decreased appetite, poor nutrition, inactivity

Often accompanied by: dehydration, depressive symptoms, impaired immune function, low cholesterol

FTT Incidence

Community: 5-35%

Nursing Home: 25-40%

Hospitalized Veterans: 50-60%

no

is FTT a diagnosis?

FTT - Associated

Increased infection rates

Decreased cell-mediated immunity

Hip fractures

Decubitus ulcers

Increased surgical mortality rates

Causes - FTT

Multifactorial

Chronic concurrent diseases

Functional impairments

Can be hard to ID or irreversible

FTT manifestations

Weight loss

Decreased appetite

Poor nutrition

Inactivity

23%

__________ of older community-dwelling people have problems with 1 or more ADLs

28%

________ of older community-dwelling people have problems with 1 or more IADLs

Up and Go Test

Patient rises from sitting, walks 10 feet, turns and returns to chair to sit

-<10 seconds: Normal

->11 seconds: at risk for falls

->20 seconds: serious fall risk

Malnutrition

When sufficient energy and/or protein is not available to meet metabolic demands

Predisposes patient to poor clinical outcomes

-increased rate of mortality

-prolonged hospitalization

-slower clinical improvement

Malnutrition Consequences

Associated with FTT

Weight loss > 5% loss in 1 month or 10% in 6 months

Normal aging: 0.1-0.2 kg loss per year after 70 yrs

1st Degree Malnutrition

85-95% of expected weight

2nd Degree Malnutrition

75-85% of expected weight

3rd Degree Malnutrition

<75% of expected weight

mortality

malnutrition is an independent predictor of what?

Malnutrition Eval Indications

Unintentional weight loss

Suspected protein or caloric malnutrition

Hospitalized patients with risk factors

-No eating within 5 days

-Nutrient losses

-Serum albumin <3.2 g/dL

-Chronic debilitating condition -> alcoholism, cancer, diabetes, renal dz, advanced age

Malnutrition Assessment

Eval Diet: caloric intake, availability of food, supplements, balance of nutrients

Trend body weight

Assess for muscle wasting

Assess for oral pathology -> dentures, poor dentition, difficulty swallowing

Food Insecurity

Cognitive Impairment

MMSE

Eval mood, social setting -> depression, delirium, look at causes (meds, social setting, elder abuse, recent loss, financial resources)

Frequent assessment is key as mental status can change quickly

≤24

MMSE score of ________ means increased odds of dementia, abnormal, mild cognitive impairment

25-26

MMSE score of ________ means decreased odds of dementia

>=27

MMSE score of _________ means no cognitive impairment

Depression

Can be a cause and consequence of FTT

Screen all FTT patients

Physical complaints more common than traditional symptoms

Delay in diagnosis and treatment -> accelerated decline

FTT Comorbidities

Infections (UTI, pneumonia)

Psych (Depression)

Neuro (Dementia, Delirium, Stroke, Parkinson)

Endocrine (Thyroid Dz, Diabetes)

MSK (Arthritis, muscle wasting)

ENT/oral (cerumen impaction, poor dentition)

Chronic Dz (COPD, CHF, CA)

FTT - HX

patient and caregiver (multidisciplinary team)

Social, environmental, meals, oral health

PX - FTT

Oral exam

ENT

Vitals (orthostatic)

Neuro

Abdominal/Rectal

MSK

Metabolic Eval - FTT

look for evidence of electrolyte imbalance, nutritional deficits, infections, hormonal problems, malignancy, etc

Imaging - FTT

CXR, other investigation for malignancy

Lab Eval - FTT

CBC (infxn, anemia)

Metabolic Panel (renal function, electrolytes)

TSH (thyroid disease)

Vit D (if low, associated with falls/decreased functional ability)

Albumin, protein, cholesterol (malnutrition markers)

UA (UTI)

decrease

what happens to cholesterol and albumin during malnutrition?

Malnutrition - Metabolic Function

Decreased Insulin

GH resistance --> GH high or normal

Increased cortisol

Decreased hepatic function

Decreased mineral stores

Malnutrition - Serum Prealbumin

<15 mg/dL

Powerful predictor of overall illness and severity

Separate test from CMP

<3.4 mg/dL

what is the value of serum albumin in geriatric malnutrition?

<200 mg/dL

what is the value of serum transferrin in geriatric malnutrition?

<1500/mm^3

what is the value of total lymphocyte count in geriatric malnutrition?

<160 mg/dL

what is the value of total cholesterol in geriatric malnutrition?

Meds that Impair Taste/Smell

Allopurinol, Alcohol, ACEi

Beta lactams, BB

CCB (except diltiazem), Chemo agents

HCTZ

Levodopa, Losartan, Lovastatin

Metronidazole

Nicotine patches, Nitroglycerin, NSAIDs

Opiates

Spironolactone

Terbinafine, Tetracycline

Conditions that Impair Taste/Smell

Illness (Covid, sinus infxn, oral infxn, allergies)

Head injury

Hormone Changes

Burns

Hx of radiation, chemical exposure, or cocaine use

Underlying Cause Tx - FTT

Infections

Chronic medical conditions - optimize tx

Depression --> SSRIs, SNRIs, Consider psych consult

paroxetine and citalopram

what SSRIs should be avoided in depression in geriatrics?

Malnutrition Treatment Plan

Diet Supplementation - Boost, Ensure, Multivitamins

Appetite Stimulants -> Mirtazapine, Marinol

Mirtazapine

helps sleep, appetite, depression

study amongst Alzheimer patients treated with this for 3 months showed they each gained 2kg on average

Megace 800 mg BID

potentially inappropriate medication to be avoided in patients 65 years and older due to an INCREASE risk of thrombotic events and potentially DEATH in older adults, with minimal SE on weight

Improving Nutrition

Soft and Colorful foods

Serve small and frequent meals

Make mealtime enjoyable -> social activity, games, tv shows

Have snacks available for easy access

Take advantage of nutritional services

Multidisciplinary Referral - Malnutrition

Dietician

Social Worker

PT and OT; consider exercise

Psychiatrist

Podiatry

Dentist

Ophthalmologist

no!

is disease a normal consequence of aging?

≥ 64 oz

how much water is needed in a day for a geriatric patient?

21-30g/day OR 14g/1000kcal

how much fiber is needed in a day for a geriatric patient?

1600-200 kcal/day for women; 2000-2600 kcal/day for men

how many calories are needed in a day for a geriatric patient?

45-56g/day

how much protein is needed in a day for a geriatric patient?

130 g/day

how many carbs are needed in a day for a geriatric patient?

<=30% of daily calorie intake

how much fat is needed in a day for a geriatric patient?