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11 - Gastrointestinal Disorders and Nutrition |
317
is different than in younger adults. A physician
should evaluate the patient for underlying issues
and to identify appropriate exercise levels. As in
younger adults, weight loss programs in elderly
patients are unlikely to be successful if exer-
cise is not an important component. Additional
protein should be included in the diet along with
sources of vitamin D, calcium, vitamin B12, fiber,
and fluids. Fad diets have a greater potential for
harm in the older adult, especially if concomitant
diseases are present.
181
Nutritional screening evaluating under-
nutrition for older adults can be accomplished
by measuring weight and height, by moni-
toring for weight loss, and through nutritional
screening tools. If body weight is below 80% of
the recommended weight or the BMI is <18.5,
further evaluation is recommended. Uninten-
tional weight loss merits further assessment
when it exceeds 4.5 kg over 6 months. Alter-
natively, a threshold based on percentage of
baseline body weight may be used: 2% over
1 month, 5% over 3 months, or 10% over
6 months. Finally, several screening question-
naires have been developed. The Mini-Nutritional
Assessment has been validated in older adults,
has been shown to correlate with outcomes,
and is widely used (see Figure 11-1). A short
form and a self-administered questionnaire are
also available online along with corresponding
instruction manuals and a smartphone applica-
tion at http://www.mna-elderly.com/mna_forms.
html. These screening tools aid the clinician in
focusing on specific issues in the evaluation.
182
In general, evaluation of an older adult
who has been screened to have undernutrition
begins with a complete history. Medications that
may cause changes in taste should be identified
and discontinued, if possible. A complete blood
count, basic metabolic panel, albumin, C-reac-
tive protein, and thyroid-stimulating hormone are
laboratory tests that may help identify treatable
underlying conditions. Malignancy should be
suspected, especially in patients with involun-
tary weight loss. The likelihood of malignancy
is further increased in patients over 80, with an
elevated white blood cell count, a decreased
albumin, or elevated alkaline phosphatase or
lactate dehydrogenase.
If underlying diseases are not found,
general treatment for sarcopenia is needed.
Dietary restrictions such as low salt and low
cholesterol diets should be removed. Some
patients with sarcopenia may still have diabetes,
with elevated blood glucose. Their diets should
be liberalized with only limits on concentrated
sweets. Hypoglycemic medication doses can
be increased to control blood sugars rather than
limit the diet of patients who are losing weight or
muscle mass. Food choices should be tailored
to patients’ ethnic or cultural preferences to
encourage increased intake.
Patients should be evaluated for the ability
to feed themselves and ability to obtain food. In
long-term care settings, many dementia patients
lose the ability to feed themselves and will eat
a healthy diet when assisted with feeding.
Other patients with stroke, Parkinson disease,
or benign essential tremor may be able to feed
themselves with appropriate silverware or medi-
cations to control movements. Economic assis-
tance may be all that is necessary to improve
the diet of patients who cannot afford their food.
Meal or food delivery services are helpful for
individuals unable to shop for groceries if family
or caregivers cannot fulfill this need. Bringing
elderly patients together for meals is preferable
to having them eat alone, as studies show more
is consumed in social settings.
Supplementation of oral intake is the next
component of the treatment plan. Some high-
calorie snacks may be appetizing and provide
the added calories and protein needed. For
example, one piece of bread with 1 tablespoon
each of peanut butter and jelly eaten with 1
cup of 2% milk yields 320 calories and 15 g of
protein. Similar snacks or nutrient-dense meals
can be concocted from hard-boiled eggs, Greek
yogurt, and instant breakfast powders, and are
relatively inexpensive.
183
Oral meal replace-
ments and supplements are another alterna-
tive and have been shown to increase weight in
patients living at home, in long-term care, and
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| Fundamentals of Geriatric Pharmacotherapy
Figure 11-1. The Mini-Nutritional Assessment (MNA).
Source: Reprinted with permission © Nestlé, 1994, Revision 2009. N67200 12/99 10M.
Mini Nutritional Assessment
MNA
®
M How much fluid (water, juice, coffee, tea, milk...) is
consumed per day?
0.0 = less than 3 cups
0.5 = 3 to 5 cups
1.0 = more than 5 cups
Assessment (max. 16 points)
Screening score
Total Assessment (max. 30 points)
.
K Selected consumption markers for protein intake
• At least one serving of dairy products
(milk, cheese, yoghurt) per day
• Two or more servings of legumes
or eggs per week
• Meat, fish or poultry every day
0.0 = if 0 or 1 yes
0.5 = if 2 yes
1.0 = if 3 yes
yes
.
Last name: First name:
Sex: Age: Weight, kg: Height, cm: Date:
Complete the screen by filling in the boxes with the appropriate numbers.
Add the numbers for the screen. If score is 11 or less, continue with the assessment to gain a Malnutrition Indicator Score.
Screening
Assessment
References
1. Vellas B, Villars H, Abellan G, et al. Overview of the MNA® - Its History and
Challenges. J Nutr Health Aging. 2006; 10:456-465.
2. Rubenstein LZ, Harker JO, Salva A, Guigoz Y, Vellas B. Screening for
Undernutrition in Geriatric Practice: Developing the Short-Form Mini
Nutritional Assessment (MNA-SF). J. Geront. 2001; 56A: M366-377
3. Guigoz Y. The Mini-Nutritional Assessment (MNA
®
) Review of the Literature - What
does it tell us? J Nutr Health Aging. 2006; 10:466-487.
® Société des Produits Nestlé, S.A., Vevey, Switzerland, Trademark Owners
© Nestlé, 1994, Revision 2009. N67200 12/99 10M
For more information: www.mna-elderly.com
Malnutrition Indicator Score
24 to 30 points Normal nutritional status
17 to 23.5 points At risk of malnutrition
Less than 17 points Malnourished
L Consumes two or more servings of fruit or vegetables
per day?
0 = no 1 = yes
Q Mid-arm circumference (MAC) in cm
0.0 = MAC less than 21
0.5 = MAC 21 to 22
1.0 = MAC greater than 22
O Self view of nutritional status
0 = views self as being malnourished
1 = is uncertain of nutritional state
2 = views self as having no nutritional problem
P In comparison with other people of the same age, how does
the patient consider his / her health status?
0.0 = not as good
0.5 = does not know
1.0 = as good
2.0 = better
N Mode of feeding
0 = unable to eat without assistance
1 = self-fed with some difficulty
2 = self-fed without any problem
yes
yes
no
no
no
J How many full meals does the patient eat daily?
0 = 1 meal
1 = 2 meals
2 = 3 meals
.
.
.
.
.
.
R Calf circumference (CC) in cm
0 = CC less than 31
1 = CC 31 or greater
I Pressure sores or skin ulcers
0 = yes 1 = no
H Takes more than 3 prescription drugs per day
0 = yes 1 = no
G Lives independently (not in nursing home or hospital)
1 = yes 0 = no
Screening score (subtotal max. 14 points)
12-14 points: Normal nutritional status
8-11 points: At risk of malnutrition
0-7 points: Malnourished
For a more in-depth assessment, continue with questions G-R
F Body Mass Index (BMI) (weight in kg) / (height in m
2
)
0 = BMI less than 19
1 = BMI 19 to less than 21
2 = BMI 21 to less than 23
3 = BMI 23 or greater
E Neuropsychological problems
0 = severe dementia or depression
1 = mild dementia
2 = no psychological problems
D Has suffered psychological stress or acute disease in the
past 3 months?
0 = yes 2 = no
C Mobility
0 = bed or chair bound
1 = able to get out of bed / chair but does not go out
2 = goes out
B Weight loss during the last 3 months
0 = weight loss greater than 3kg (6.6lbs)
1 = does not know
2 = weight loss between 1 and 3kg (2.2 and 6.6 lbs)
3 = no weight loss
A Has food intake declined over the past 3 months due to loss
of appetite, digestive problems, chewing or swallowing
difficulties?
0 = severe decrease in food intake
1 = moderate decrease in food intake
2 = no decrease in food intake
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11 - Gastrointestinal Disorders and Nutrition |
319
in hospitals. However, functional status is less
responsive. Mortality reduction has been shown
in hospitalized undernourished patients with
supplementation. Boost, Magic Cup, Glucerna,
and Ensure are common brand names frequently
used. In addition, most sources recommend a
geriatric multivitamin with minerals supplement
given daily. Some studies show a decrease in
infections for older adults taking multivitamins
with minerals; however, a recent large cohort
study of older women showed a small increase
in mortality for those taking daily multivitamins
(hazard ratio 1.2, 95% CI 1.02–1.10).
184,185
Appetite stimulants are sometimes
prescribed for older adults to help with weight
gain. Dronabinol is indicated for AIDS-related
anorexia. Little evidence exists in elderly popula-
tions, and in general it is not well tolerated due to
the CNS effects.
Megestrol acetate has been shown
modestly effective for cachexia associated with
cancer or AIDS in younger adults. A few studies
exist in elderly patients without these disorders,
and results have been mixed, with some patients
adding weight and others not. The weight is not
uniformly shown to be lean body mass; therefore,
it is unclear that the risk for adverse effects (e.g.,
deep-vein thrombosis, adrenal axis suppression)
is outweighed by its efficacy. Doses commonly
prescribed are 400–800 mg per day, which
is difficult to achieve with tablet formulations.
Usually, the oral suspension is used to achieve
this dose.
186
Mirtazapine is also used for appetite stim-
ulation as it possesses histamine-1 receptor
antagonism. Dosing begins at 7.5 mg at bedtime
and may be increased to 15 mg. Studies have
focused on weight gain in patients with concomi-
tant depression or dementia with depression
and show an increase of 2–4 kg over 6 weeks.
However, this is not significantly different from
other antidepressants when used to treat depres-
sion. Evidence of efficacy is not available for
undernourished patients without depression.
186
Given the generally favorable adverse effect
profile of mirtazapine, it remains a reasonable
choice for patients with weight loss that is asso-
ciated with depression. The use of mirtazapine
as an appetite stimulant in individuals without
depression has not been sufficiently evaluated.
The Institute of Medicine has recommended
dietary intakes for macronutrients, vitamins, and
minerals. Those recommendations are different
in older adults because of changes in physi-
ology and overall food intake. In general, protein
intake recommendations are 0.8 g/kg per day to
make up 10% to 35% of total calories to maintain
muscle mass equilibrium. Older adults who need
to build muscle mass require 1–1.2 g/kg. Energy
needs tend to decrease with aging because of
lower muscle mass and an increased seden-
tary lifestyle. The calories derived from carbo-
hydrates and fat would be reduced as physical
activity decreases; however, a minimum amount
from carbohydrates is needed to maintain brain
function. Table 11-2 provides the dietary reference
intakes of macronutrients and selected micronu-
trients for older adults.
187
These are considered
minimum values.
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Table 11-2. Selected Dietary Reference Intakes for Older Adults
Macronutrients
Energy
(kcal)
Protein
(g)
Carbohydrates
(g)
Total Fat
(% kcal) Fiber (g)
Water
(L)
Age 51–70
Male
2204 56 130 20–35 30 3.7
Age 51–70
Female
1978 46 130 20–35 21 2.7
Age 70+
Male
2054 56 130 20–35 30 2.6
Age 70+
Female
1873 46 130 20–35 21 2.1
Selected Vitamins and Minerals
Vitamin D
(mcg)
Vitamin
B12 (mcg)
Calcium
(mg) Iron (mg)
Magnesium
(mg)
Zinc
(mg)
Age 51–70
Male
10 2.4 1200 8 420 11
Age 51–70
Female
10 2.4 1200 8 320 8
Age 70+
Male
15 2.4 2500 8 420 11
Age 70+
Female
15 2.4 2500 8 320 8
Source: Data from National Policy and Resource Center on Nutrition and Aging. Florida International
University.
187
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C 1: H G C
Setting:
Hospital.
Subjective:
BJ is an 83-year-old community-dwelling woman who presented to the geriatrics clinic with
a 2-day history of abdominal cramping and 8–10 loose, watery bowel movements each day.
Three weeks ago she was treated for abdominal cellulitis with vancomycin and piperacillin/
tazobactam ×2 days followed by clindamycin and levofloxacin to complete a 14-day course.
Her last dose of antibiotics was 4 days ago.
Past Medical History:
Insulin-dependent diabetes mellitus, rheumatoid arthritis, and hypertension.
Medications:
Amlodipine 10 mg daily, prednisone 5 mg daily for arthritis, glipizide ER 5 mg daily,
methotrexate 25 mg once weekly on Tuesdays, omeprazole 20 mg daily before breakfast,
aspirin 81 mg daily.
Allergies:
NKDA.
Social History:
Lives alone with four children nearby for support.
Objective:
Ht 5´4˝, Wt 158 lb, BP 127/57; P 95 BPM; RR 20; T 99.8°F.
Physical Examination:
Within normal limits except for arthritic changes in digits, guarding, and tenderness on
abdominal exam with healed wound/scar tissue on lower abdomen.
Labs/Radiology:
Electrolytes within normal limits; BUN 26 mg/dL; serum creatinine 1.2 mg/dL, WBC 15.75 K/uL;
stool specimen for C. diff. toxin positive.
Assessment:
BJ is an 83-year-old woman on immune suppressant therapy and recent broad-spectrum
antibiotic treatment who presents with abdominal tenderness and diarrhea consistent with C.
diff. diarrhea. Dehydration with acute kidney injury is also present.
Plan:
1.
Begin metronidazole 500 mg every 8 hours for 14 days.
2. Adopt isolation precautions with gloves/gowns until diarrhea resolved. Strict handwashing
protocol required.
3. Hold methotrexate and omeprazole for now.
4. Give 500 mL bolus of normal saline intravenously. Repeat basic metabolic panel tomorrow.
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Rationale:
1.
This patient has several risk factors for developing C. diff. diarrhea, including treatment
with clindamycin, immunosuppressant therapy, advanced age, recent hospitalization,
and potential use of a PPI. Although her infection is not within the median 2–3 days of
antibiotic treatment, she does have exposure within the past 8 weeks, which is a risk
factor. Metronidazole is the recommended antibiotic therapy for C. diff. diarrhea for initial
cases unless the disease is life-threatening, which would require treatment with oral
vancomycin. A 10- to 14-day course is suggested, and given this patient’s risk factors of
immunosuppressant therapy and advanced age, the longer course is reasonable to select.
2.
One of the most important aspects of C. diff. infection is the need to prevent spread of
the organism and its spores to others. Strict handwashing and isolation procedures are
recommended to accomplish this goal.
3.
Immunosuppressant therapy increases the patient’s risk for developing a C. diff. infection
and may inhibit rapid clearance from the body. Discontinuation of immunosuppressants is
desirable; however, the long-term use of prednisone may have caused suppression of the
hypothalamic-pituitary axis, and discontinuation of prednisone during an acute illness is
not recommended. PPIs have been associated in some studies with increasing risk for C.
diff. diarrhea; in addition, this patient has no current indication for use.
4.
With an elevated serum creatinine and BUN coupled with the lower blood pressure and
episodes of diarrhea, a bolus of normal saline to replace lost fluids is indicated to try and
reverse the dehydration and acute kidney injury. Continued monitoring of electrolytes and
renal function is important for a patient with several days of diarrhea and acute kidney
injury.
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C 2: N H
Setting:
Nursing home.
Subjective:
RW is a 79-year-old resident of a nursing home who was identified by his son and niece as
having poor oral intake and progressive weakness. He was admitted to the nursing home’s
rehabilitation ward 7 months ago after suffering a stroke and did not require help for dressing,
feeding, or ambulation when finished with his therapy. However, over the past 2 months he
has lost 10 kg and is no longer able to ambulate without assistance. RW complains that food
seems to stick in his throat, and he coughs after he drinks or eats more often than he used to.
Two days ago he had worsening pain in his ankles and feet and was started on prednisone for
a presumed gout attack.
Past Medical History:
Hypertension, gout, stroke, chronic kidney disease (baseline serum creatinine 1.5 mg/dL), and
healthcare–associated aspiration pneumonia during previous hospitalization.
Medications:
Nifedipine extended release 60 mg daily, aspirin 81 mg daily, colchicine 0.6 mg daily,
prednisone 20 mg daily ×5 days.
Allergies:
NKDA.
Social History:
Quit smoking in 2000, no history of alcohol or drug abuse.
Objective:
Ht 5´6˝, Wt 128 lb; BP 120/62 mmHg; P 69 BPM; RR 18/min; T 97.1°F.
Physical Examination:
Frail-appearing elderly male; examination within normal limits except for dry mucous
membranes, white patches on tongue and back of throat, bilateral lower extremity weakness,
and reduced range of motion in ankles.
Labs:
Laboratory within normal limits except for sodium 134 mEq/dL, BUN 33 mg/dL, serum
creatinine 1.6 mg/dL; INR 1.3.
Assessment:
RW is a 79-year-old male with weakness, weight loss, and oral thrush.
Plan:
1.
Begin nystatin suspension swish and spit three times daily for 5 days.
2. Give medications with at least 4 oz of water.
3. Schedule for speech and physical therapy.
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Rationale:
1.
RW has complaints consistent with dysphagia, including food sticking in his throat and
cough. In addition, he has dry mucous membranes and oral thrush, both associated with
swallowing difficulties. For several months he has had a decrease in oral intake evidenced
by weight loss, which will worsen with development of oral thrush. Oral thrush is a well-
recognized contributor to dysphagia and requires treatment with nystatin or fluconazole.
This patient is on a short course of prednisone for a flare of gout. Once the prednisone is
discontinued, he will likely not need long-term treatment with nystatin.
2.
When it becomes more difficult to swallow, patients are likely to take medications with
a minimal amount of fluid, which may prevent their proper dissolution and absorption. In
RW’s case the aspirin may lodge in the throat and cause discomfort.
3.
RW has a history of stroke and aspiration pneumonia, increasing his risk for dysphagia.
He may have recovered his ability to swallow in the first months after the stroke with
speech therapy, but sometimes patients do not continue to adhere to speech therapy
recommendations for swallowing techniques and exercises, and dysphagia may return. A
re-evaluation (after treatment of oral thrush) could prove helpful in assessing his present
abilities and identifying current exercises and techniques to improve his overall ability to
swallow. In turn, this may allow him to increase fluid and protein consumption, reversing
the downward trend in his activities of daily living.
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C S
Aging changes the physiology of the GI tract and
the body’s nutritional needs. Elderly patients are
at increased risk for many GI problems such as
GERD, nausea and vomiting, dysphagia, diver-
ticular disease, constipation, fecal incontinence,
and C. diff. diarrhea. In addition, oral health and
nutritional status can deteriorate, increasing the
risk for sarcopenia and frailty. The use of avail-
able pharmacotherapies for treating GI disorders
in the older population differs in many respects
from use in younger adults. Understanding the
epidemiology of GI and nutritional disorders in
older adults and their evidence-based manage-
ment can help eliminate disparities in healthcare
and promote quality of life and longevity for our
aging population.
S-A Q
1. What physiologic changes related to aging
increase the risk for GI disorders in older
adults?
2. Why should complaints of dry mouth or
altered taste sensation prompt a drug
regimen review?
3. Which products are most likely to present a
challenge when administering medications
to an individual with dysphagia?
4. What are the important considerations when
evaluating the presence of a PPI on the
regimen of an elderly patient?
5.
What are the most common causes of
nausea among the elderly population?
6.
What are the differences among anorexia,
cachexia, and sarcopenia?
7.
What medications cause constipation?
8. When is vancomycin a better choice for
treating C. diff. infection than metronida-
zole?
9. What is the most common reason an older
person develops fecal incontinence?
10.
Which antibiotics are best for treating diver-
ticulitis?
R
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•
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