5. DETERMINE (13–15)
9.3 EARLY INTERVENTIONS TO INCREASE FOOD AND FLUID INTAKES
Body weight, although sometimes difficult to obtain in older patients, should be routinely monitored. A chair or bed scale can be used for those unable to stand.
Height measures can also be problematic. When ascertaining height for calculation of BMI, it will be best to use the patient’s height before age 50 as the reference height in order to avoid the effects of kyphosis due to osteoporosis(26). If weight loss and/
or low BMI are confirmed, the frequency of monitoring weight for that patient should be increased to weekly intervals(27). In the nursing home setting, interven- tions should be considered for patients who have lost 5% of usual body weight in 30 days or 10% in 6 months(28), using the calculation of weight change percent as usual weight—current weight/usual weight$100. The algorithm in Fig. 9.2 illus- trates many of the recommended approaches for correcting problems with nutri- tional adequacy when unintentional weight loss is a concern. Strategies to utilize in patients for whom improving oral intake is a viable option are discussed in this section.
9.3.1. Therapeutic Interventions
Clearly, correction of any underlying medical cause for weight loss should be the first step employed to help counteract low food intake. Unfortunately, it is the rare situation when this is possible, either because no treatment is able to resolve the condition or because the primary cause of the anorexia is unknown. Other causes Table 9.2
Causes of undereating-related weight loss
Physiologic/pathologic Psychologic Socioeconomic
Appetite/food intake regulation(84)
Depression Social and/or geographical isolation, loneliness (31,85)
Oral health problems(86,87) Dementia(88–90) Lack of caregiver support Sensory impairments Other cognitive
impairments
Food insecurity Altered absorption or digestion Longstanding
emotional or mental illness
Institutionalization and decreased access to food (91,92)
Acute and chronic diseases, associated therapies Difficulty with self-feeding
(physical or neurological disability)
Dependence on enteral or parenteral feeding(93,94)
Chapter 9/ Redefining Nutritional Frailty 161
such as reduced access to food, depression, social isolation, poor dentition, and over-medication are more amenable to correction and every effort should be made to remove these barriers when they are impeding food intake.
9.3.2. Improving the Dining Environment and the Nutritional Value of Food Choices
There is growing evidence of the measurable impact of improving the aesthetics of the food and dining environment on the food intake of frail patients. Mathey et al. (29) instituted improvements in meal ambiance focused on the physical environment and atmosphere of the dining room, quality of food service, and nursing staff assistance for 38 elderly residents of a Dutch nursing home. After 1 year, in contrast to the control group, the 22 residents who completed the study had increased body weights (+3.3 kg,P<0.05) and stable health status assessments.
The importance of socialization and support at mealtime should not be under- estimated(30). Locher et al.(31)demonstrated the value of the presence of others at mealtime, reporting that persons who had others present during meals consumed an average of 114.0 calories more per meal than those who ate alone (p =0.009).
Nijs et al.(32)conducted a randomized controlled trial of providing family-style meals to older residents in five Dutch nursing homes and observed significant improvements in daily energy intakes. There was a decrease in the proportion of residents in the intervention group scored as malnourished by the Mini Nutritional
Unintentional Weight Loss
(Patients at risk for Nutritional Frailty)
Identify Contributing factors
(nutritional screen, history, and physical exam)
Intervene based on Assessment Promote Oral Intake
Nutritional Adequacy Achieved Continued Nutritional Decline
Identify Nutritional Goals with Patient & Family
• Provide food & liquids as desired and accepted.
• Provide oral hygiene
• Remove dietary restrictions
• Enlist family support
• Vitamin/Liquid supplements
• Appetite stimulant
• Feeding assistance
• Favorite/Familiar foods
• Minimize distractions
• Small frequent meals/snacks
• Dental referral
• Nutritional consultation
• Speech therapy referral for dysphagia mgt
• Maximize disease mgt
• Remove offending drugs
Restore/Maintain:
Utilize alternative feeding methods
• Enteral Feeding
• Parenteral Feeding (Most appropriate in setting of acute/reversible illness.)
Restore/Maintain:
Promote oral intake
• Identify contributing factors
• Try new interventions
Palliative Nutritional Support (Appropriate when condition is terminal
and/or intervention is undue burden) Monitor/Promote Maintenance
Fig. 9.2. This algorithm to guide care providers as they identify, assess, and treat weight loss and nutritional frailty in older adults living in the community was previously published by Bales and White(82)and is reprinted with permission.
162 Bales and Ritchie
Assessment from 17 to 4%, whereas the percentage malnourished increased from 11 to 23% in the control group. Altus et al.(33)found that serving meals family style led to modest increases in mealtime participation and communication even in residents with dementia and very low pre-study rates of appropriate communica- tion. These and other findings provide strong justification for emphasizing improvements in the taste, presentation, and social setting of meals for the older patient with clinically important unintentional weight loss.
Along with improving the esthetic appeal of the food and the presence of others at meals, it is also important to optimize the nutrients provided in the meal and snacks that are offered. Lorefalt et al.(34)enriched the energy and protein content of small meals offered to 10 patients on a geriatric rehabilitation ward and increased the daily energy intake by 37%, accompanied by an increase in the intakes of protein, fat, carbohydrate, certain vitamins, and minerals. Odlund Olin et al.(35) were able to demonstrate similar findings, along with preservation of Activities of Daily Living (ADLs), by providing energy-dense meals to 35 nursing home residents (median age¼83 years). Zizza et al.(36)found that older adults who ate between- meal snacks had significantly higher daily intakes of energy, protein, carbohydrate, and total fat, with snacking contributing 14% of their daily protein intakes. Table 9.3 provides a list of easy-to-eat foods and snacks along with their caloric and protein density per gram of food.
Bernstein et al. (37) found measurable improvements in dietary quality when they provided nutrition education to community-dwelling elders with functional impairments, demonstrating the value of including older adults in the effort to improve their nutrient intakes whenever this is feasible. Included in the nutrition education should be an emphasis on choosing a wide variety of nutritious foods.
Roberts et al.(38)reported that older adults with low BMIs (<22 kg/m2) consumed a lower variety of energy-dense foods compared with older adults with higher BMIs (p <0.05) and Bernstein et al. (39) found a highly varied diet to be linked with better nutritional status in nursing home residents as assessed by nutrient intake, biochemical measures, and body composition measures.
Another important step in enhancing food intake and nutritional status is the lifting of dietary restrictions whenever possible so as to offer a wider selection of food choices. A therapeutic diet prescription may be unnecessary for frail, under- nourished patients and can often be bypassed even in diabetic patients, provided they are being regularly monitored(40). The American Dietetic Association sup- ports removing restrictions as a way of enhancing food intakes(41).
9.3.3. Providing Feeding Support and Assistance
When the process of eating and swallowing are physically affected by age- or disease-related changes, the loss of the ability to adequately self-feed can place the older patient at high nutritional risk. An approach called functional feeding suggested by Van Ort et al.(42)emphasizes a behavioral approach that involves the patient and encourages interaction between the patient and feeder throughout the meal. Feeding approaches that emphasize touch and/or verbal cueing have been used successfully for older patients who were severely cognitively impaired(43). However, it should be
Chapter 9/ Redefining Nutritional Frailty 163
Table 9.3
Calorie and protein content of familiar foods and snacks of high caloric density
Food
Serving size, typical and
(g)
Calories Energy density (kcal/g)
Protein (g)
Protein density (g protein/g) Main meal components and meal replacements
Bagel with cashew butter
½Bagel (28) 2 T. cashew
butter (30) Total (58)
72 180 252
2.6 6.0 4.3
2.5 2.8 4.5
0.089 0.093 0.078 Whole-wheat eggo
waffle
1 Waffle (35) 90 2.6 2.5 0.071
With butter and syrup
2 T. butter (9.5)
1 T. syrup (60) Total (104)
68 158 316
7.2 2.6 3.0
0.08 0 2.6
0.008 0 0.025 Carnation instant
breakfast drink
8 Fluid ounces (281)
250 0.9 13.0 0.046
Peanut butter sandwich
2 Slices bread, wheat (50) 2 T. peanut
butter (32) Total (82)
130 190 320
2.6 5.9 8.5
5.0 8.2 13.2
0.10 0.256 0.16 Cream soup,
chicken, made with whole milk
6 oz. (186) 109 0.6 5.5 0.029
Macaroni and cheese –Home recipe –Box type
½cup (100)
½cup (100)
215 160
2.2 1.6
8.4 7.0
0.084 0.07 Fried chicken 1 leg (62)
½Boneless chicken breast (98 g)
162 218
2.6 2.2
16.6 31.2
0.268 0.318
Mashed potatoes with gravy
½Cup potatoes (105) 2 T. gravy (30) Total (135)
81
25 106
0.8
0.8 1.6
2.1
0.5 2.6
0.02
0.016 0.019 Health choice
frozen dinner –Grilled chicken
1 Meal (284) 270 0.95 22 0.077
Apple pie ½Slice pie (89)
265 2.9 2.0 0.022
Ice cream, vanilla 1 Scoop ice cream (70)
150 2.2 3.0 0.043
(continued )
164 Bales and Ritchie
noted that not all patients benefit equally from feeding assistance(44). Because of the intensive and time-consuming nature of this approach, Simmons et al.(45)recom- mend a trial of feeding assistance for the purpose of identifying those individuals who are likely to be responsive to intense feeding assistance.
9.3.4. Use of Appetite Stimulants (Orexigenic Agents)
As previously noted, in many cases of undernutrition the underlying cause of poor food intake is NOT inferior appetite. However, in situations when poor Table 9.3
(continued)
Food
Serving size, typical and
(g)
Calories Energy density (kcal/g)
Protein (g)
Protein density (g protein/g) Pudding,
chocolate, ready to eat
1 Snack cup (113)
110 1.0 2.0 0.017
Between-meal snacks Cheddar cheese on
crackers
2 oz. Cheese (57) 4 Saltine
squares (11) Total (68)
223 50 273
3.9 4.6 8.5
14.2 1.0 15.2
0.249 0.09 0.223 Yogurt, full fat,
flavored
8 oz. (227) 253 1.1 10.7 0.047
Crunchy granola bar
2 Bars (42) 180 4.3 5.0 0.119
Cliff energy bar 1 Bar (68) 230 3.4 10.0 0.147
Peanuts, dry roasted
2 T. (19) 107 5.8 4.3 0.226
Walnuts, pieces ¼Cup (25) 180 7.2 3.5 0.14
Hershey chocolate kisses
6 (28) 145 5.1 2.0 0.071
Milkshake, chocolate
–Fast food type 8 oz. (147) 174 1.2 6.3 0.043
Condiments and add-ons
Olive oil* 2 T. (27) 239 8.8 0 0
Nonfat dry milk powder**
2 T. (15) 54 3.6 5.4 0.36
Soy sauce 2 T. (36) 22 0.61 4.0 0.11
Barbeque sauce 2 T. (30) 60 0.66 1.0 0.03
Mustard 2 tsp. (10) 6.6 0.66 0.4 0.04
*Can be added as source of calories to savory sauces and foods.
**Can be used to fortify beverages, soups, puddings, and sauces.
Chapter 9/ Redefining Nutritional Frailty 165
appetite is known to be an important contributor to undernutrition, pharmacologic appetite stimulants (orexigenic agents) may be considered if improved appetite would be an important contributor to the individual’s quality of life. As illustrated in Table 9.4, the available armamentarium for improving appetite in older adults is rather limited, depending primarily on agents approved for use in patients with
Table 9.4
Medications and supplements with potential benefits for appetite and/or weight gain*
Medications/
supplements
Potential side effects Recommended regimens
Megestrol acetate (48,50,57,95,96)
Edema, hypertension, deep vein thrombosis, adrenal suppression, blunting of muscle response to exercise (51)
400–800 mg/day; treatment course should be no longer than 8–12 weeks
Dronabinol (52,95,97)
Sedation, fatigue, and hallucinations. Not recommended for patients who are cognitively compromised or prone to falls
2.5 mg initially in the evening.
Increase to 5 mg per day after 2–4 weeks
Anabolic agents Masculinization, fluid retention, hepatic toxicity
Oxandrolone: 2.5 mg 2–4 times/day Protein and amino
acid
supplements
Renal protein overload, gout and hyperuricemia-related complications
Total protein intake up to 1.6 g protein/kg/day
Isoleucine RDA: 25 mg/g protein**
Leucine RDA: 55 mg/g protein**
Valine RDA: 32 mg/g protein**
Creatine: 20 g/day for 5–6 days***
Omega-3 fatty acids and fish oil (57)
Gastrointestinal side effects, potential effects on red blood cell structure, function
Recommendation for healthy adults is 0.3–0.5 g/day EPA+DHA, with about 1 g/
day for patients with coronary heart disease(98).
Dose level for treatment of weight loss is unknown
*Table is based on part on the review by Yeh et al., 2007(46).
** Rehabilitation-level doses of specific amino acids are not determined. Values shown are recommendations for healthy adults. From Dietary Reference Intakes: Macronutrients.
*** Rehabilitation-level doses of creatine are unknown. Values shown are from Greenhaff et al.(99).
166 Bales and Ritchie
cancer or HIV/AIDS (46). All of the pharmacologic agents have a meaningful negative side effect profile. Currently, there are no orexigenic drugs approved by the FDA for the treatment of age-related anorexia.
Megestrol acetate (Megace) is a synthetic progesterone derivative that has anti- inflammatory and glucocorticoid activity. Several studies of megestrol acetate have shown moderately encouraging results, with modest positive effects on appetite, weight gain, and quality of life. Because megestrol is a strong catabolic hormone, it should only be given on a temporary basis (no longer than 8–12 weeks at a time).
However, its effects can continue to be seen after discontinuation and the drug can be given again if needed after a 3- to 6-month rest period (46). Recently, a nanocrystal formulation of the drug (Megace ES) has become available; it can be given at a lower dosage and is more soluble so that it may be better absorbed when given between meals(46).
In one of the first studies of this medication in older adults, Yeh et al. (47) reported that 800 mg/day of megestrol acetate increased appetite, food intake, and (in 3 months) body weight in nursing home patients who had lost 5% or more of their body weight. Karcic et al. (48)reported improvement in nutritional para- meters (including food intake and BMI) in 13 megestrol-treated nursing home patients for whom other methods of nutritional support had failed. Simmons et al.(49)noted little benefit using Megace OS alone but, when used in combination with optimal mealtime feeding assistance, there was a significant increase in oral intakes of frail nursing home patients at high risk for weight loss. Reuben et al.(50) randomized 47 older persons (mean age 83 years) who were post-hospital discharge with fair or poor appetite to a placebo or a megestrol acetate suspension providing 200, 400, or 800 mg daily for 9 weeks. The megestrol acetate doses of 400 and 800 mg were associated with increased levels of plasma prealbumin, but cortisol suppres- sion wascommonat the higher doses. Other potential side effects of this orexigenic agent include edema, hypertension, adrenal suppression, and thromboembolism.
Another potential concern about megestrol acetate is the observation by Sullivan et al.(51)that in subjects (mean age 79.4&7.4 years) participating in a randomized trial of resistance training alone or with megestrol acetate, the addition of the drug appeared to blunt the beneficial effects of resistance training, lessening the antici- pated gains in muscle strength and functional performance. One solution for this problem might be to institute the resistance training in post-megestrol-treated patients(46).
Dronabinol (tetrahydrocannabinol, a cannabis derivative with FDA approval for use in HIV/AIDS and cancer) has been suggested as a possible agent to increase appetite and lead to weight gain in geriatric patients. It has been suggested as a promising choice when anorexia is secondary to nausea and is best given in the evenings due to its sedative effects. A retrospective observational study of residents with anorexia and weight loss in five long-term care facilities on a 12-week course of dronabinol showed that the drug was well tolerated; 15 of the 28 treated subjects gained weight(52). In a placebo-controlled crossover study, with each treatment period lasting 6 weeks, 15 patients with a diagnosis of probable Alzheimer’s disease who were refusing food were treated with dronabinol. In the patients who tolerated the treatment and could remain in the study (n¼11), there was an increase in body
Chapter 9/ Redefining Nutritional Frailty 167
weight and a decrease in severity of disturbed behavior. The adverse reactions of euphoria, somnolence, and tiredness did not necessitate discontinuation of the treatment. Nonetheless, with the potential side effects of sedation and hallucina- tions, dronabinol may not be an appropriate choice for confused elderly patients or those prone to falls (46). A study comparing megestrol acetate and dronabinol treatment in advanced cancer patients showed superior effectiveness for megestrol;
combination therapy with the two drugs provided no additional benefit(53).
Anabolic drugs such as oxandrolone and nandrolone are known to produce increases in lean mass in body builders and have been considered for their potential benefit in frail older patients with loss of lean body mass and in those with chronic wasting conditions like COPD(54). Schroeder et al.(55)found that oxandrolone (10 mg twice daily) produced substantial increases in lean body mass as well as decreases in total body and trunk fat mass in older men (72&6 years). While such effects are hormonal, not nutritional, they could interact with nutritional para- meters like metabolic rate and insulin sensitivity. Anabolic agents have a host of potential side effects such as hepatotoxicity, hypogonadism, testicular atrophy, gynecomastia, and psychiatric disturbances. There is insufficient study in older subjects at this time to enable us to make clinical recommendations and their use is confined to controlled studies(56).
Various amino acids and fatty acids are listed in Table 9.4 but the potential for these compounds to be used as agents to improve weight status have not been fully studied. To date, findings regarding their benefits are not particularly encouraging.
A comparison of eicosapentaenoic acid (EPA) supplement with Megace treatment showed that subjects did not have better improvements for weight or appetite, whether the EPA was given alone or in combination with the Megace(57).
9.4 INTERVENTION WITH NUTRITIONAL (PROTEIN/CALORIE)