Managing Involuntary Weight Loss in Older Adults
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Transcript of Managing Involuntary Weight Loss in Older Adults
Managing Involuntary Weight Loss in Older
Adults
Jeannine Lawrence, PhD, RD, LDDivision of Human Nutrition
Learning Objectives
• Identify potential causes of involuntary weight loss in older adults (OAs)
• Explore the potential impact of involuntary weight loss on physical function and health outcomes in this population
• Describe the goals of weight management in OAs during illness
• Discuss effective, multidisciplinary strategies for ameliorating involuntary weight loss in OAs
Definitions & Prevalence
• Unintentional weight loss - loss of body mass that can occur due to illness or disease, stress, psychological conditions, and/or unknown causes
• Weight loss = >3% of body weight or 2 kg• Clinically relevant – >5% body weight in 6 months• “Problematic” weight loss – ≥5% in 1 month– ≥10% in 6 months or longer
US Omnibus Budget Reconciliation Act of 1987
Definitions & Prevalence (cont.)
• Undernutrition - common in older adults (Clinics in Geriatric Med. 2002)
– 5-12% of community-residing older adults– 11% of medical outpatients– 20% of higher-risk, community-residing– 32-50% of hospitalized
• Involuntary weight loss– Affects 15-20% of older adults– Contraindicated in the OA• Including the obese OA
Factors Associated with Unintentional Weight Loss
M – Medication effectsE – Emotional problems, esp. depressionA – Anorexia nervosa, alcoholism, abuseL – Late-life paranoiaS – Swallowing disorders
O – Oral factors (e.g. taste, teeth, poorly fitting dentures, caries)N – No money (poverty)
W – Wandering and other dementia-related behaviorsH – Hyper- and hypothyroidism, hyperparathyroidism,
hypoadrenalismE – Enteric problemsE – Eating problems (e.g. difficulty/inability to feed self)L – Low-salt, low-cholesterol dietsS – Shopping or social issues (e.g. inability to obtain preferred foods,
isolation, etc) Morley 1995
Comparison of Causes of Unintentional Weight Loss in OA
No iden
tified ca
use
Psychiat
ric diso
rder
(inclu
ding dep
ressio
n)
Cancer
Benign
GI diso
rder
Medica
tion effect
Neuro
logic diso
rder
Other (hyp
othyroidism
, poor in
take,
TB, fo
od avoidan
ce, DM, e
tc)0
10
20
30
40
50
60
70
OP (n=45)LTC (n=185)IP (n=154)OP + IP (n=91)
Huffman 2002
Functional & Health Outcomes
• Physical function– loss of skeletal muscle mass→ frailty →
decreased mobility
• Health Outcomes– exacerbate disease –↓ immune function– ↑ morbidity and mortality
Nutrition Screening Tools• DETERMINE and MNA – extensively validated,
identify at-risk OAs• Nutrition Screening Initiative (NSI) – 25 national
health and aging organizations– Developed the Determine Your Nutritional Health
Checklist to highlight warning signs of malnutrition– Level I – BMI, weight change, eating habits, living
environment, and functional status questions – Level II – anthropometrics, lab data, clinical exam,
cognitive/mental status evaluation Lipschitz 1992
Nutrition Screening Tools (cont.)•Mini Nutritional Assessment (MNA) – short and long forms
Step 1 - Assessment
• Anthropometrics (ht, wt, wt change)– BMI
• height may be inaccurate 2° osteoporosis • may not be an accurate estimate of lean mass• 24.0-29.0 may be optimal Beck 1998
• Medical hx, labs• Medications and supplement use• Physical function, physical activity (↓
associated with poorer appetite)• Psycho/Social – cognition, depression, social
support and interaction
Dietary Intake Assessment in OAs
• Methods– Diet records– 24-hr dietary recall– FFQ– Diet history
• Validity of multiple methods are comparable to younger adults
Special Considerations for Dietary Intake Assessment in OA
• Memory impaired– Must assess cognitive abilities– Avoid - Recall, FFQ– Add – memory strategies (multiple pass, product
recognition), prior notification of interview, combining methods
– Caregiver interview beneficial• Physical limitations – arthritis, eyesight, etc– Avoid – self-administered tools
Special Considerations for Dietary Intake Assessment in OA (cont.)
• Altered dentition – Probe for specialized food prep
• Chronic illness & specialized diets– May introduce bias (both + & -)
• Supplement use
Step 2 - Weight Management
• Identify and treat the underlying cause, then -
• Dietary goal1. Stop the weight loss2. Plan for weight regain (when
appropriate)• What is reasonable?• +250-500 kcal/day or up to 35 kcal/kg
• Provide favored foods– If sweets, choose more nutrient-dense options:
pudding > cookies > hard candies
• Increase snacking, but monitor effect on meals• Get creative in masking nutrients to ↑ nutrient
density without ↑ing volume– Adding protein powders (whey), fiber
supplements, fats/oils to foods and beverages– Cookbooks available for hiding vegetables in
meals (targeted to parents)
• Diet liberalization – often warranted
Interventions to Improve Intake:Problem- Decreased Volume
• Keep nonperishable, ready-to-eat foods available
• Batch cook and freeze complete meals that can be microwaved (avoid stove reheating if fatigue or cognition is an issue)
• Consider enrollment in a community meal provider service (like Meals on Wheels)
Problem: Decreasing Ability to Prepare Foods
• Provide visual cues– Place foods and beverages in areas
where OA will see them– Attach notes with reminders to eat in
high-traffic areas
• Offer foods regularly• Have OA eat with others (in a
controlled setting)
Problem: Forgetting to Eat or Drink
• Due to ↓ taste and smell acuity or medication side effects– ↑ spices to enhance flavor– Serve foods warm to increase aroma– Cook other foods that smell delicious at mealtimes
• Cookies, bread
• Due to reduction in PA– ↑ PA
• Due to fatigue– Maximize on best meal –typically breakfast– Offer small snacks periodically– Make every food/beverage count
Problem: Loss of appetite
• Eat with others• Easily distracted– Eat with others so all are performing the
same task– Serve meals in a quiet, pleasant,
controlled environment– Use plain plates and tablecloths
Problem: Isolation, Depression, or MCI
• Dental eval• Swallowing evaluation – may require
medical intervention– Texture-modified foods– Thickened liquids
• Dehydration risk
• Supplements – an option, offer >1hour apart from meals– consider whole milk with CIB
• Supplemental enteral feeding, or full enteral feeding
Problem: Dental, Chewing, or Swallowing Issues
Additional Methods to Ameliorate Weight Loss
• Engage social and family support• Increase physical activity• Address fatigue, sleeping issues
Management During Illness
• Be proactive and aggressive–Weight loss is a downward spiral
• Consider it a comorbidity (to primary diagnosis) when developing tx plan
Medications and Supplements that May Increase Appetite*
Comments
Megace Do not use – contraindicated for use in OAs
RemeronTrazodoneDexamethasoneMarinol Anti-anxiety, anti-nauseaMetoclopromide Avoid unless for gastroparesis Ornithine oxoglutarate (OGO)
* All except Megace are non-FDA approved for this usage in this population
Summary
• Involuntary weight loss -15-20% of older adults– Contraindicated in the OA, including the
obese• Interventions require a
multidisciplinary approach– Begin with identifying the cause– Assess the patient from medical,
pharmacological, nutrition, and sociological perspectives
– Address weight management plan from multiple avenues
Case StudyA 73-year-old woman presents to
your clinic complaining of unintentional weight loss. She reports having lost 15 lbs (6.8 kg) over the past year. She reports that she is eating three meals per day as usual.
The patient’s past medical history is notable for:
• Osteoporosis• Left hip fracture three years• Osteoarthritis with osteoarthritic
changes in the knees• Hypothyroidism• Hypercholesterolemia. • Radiograph of the chest, CBC,
electrolytes, creatinine, TSH, and albumin are WNL.
Medications• levothyroxine • a statin • a bisphosphonate • vitamin D and calcium • nonsteroidal anti-inflammatory
medications (NSAIDs; prn for knee pain)
She is an ex-smoker and does not drink alcohol.
Weight -120 lbs (54.5 kg) Usual weight - 135 lbs (61.3 kg)89% of UBWBody mass index (BMI) - 22.0.
Adapted from Alibhai CMAJ 2005
Case Study (cont.)
On further questioning, the patient admits that:• Even though she had been eating three meals per
day, she eats less at each meal than previously. • Her husband of 50 years died suddenly 10 months ago.
– She reports her mood is fine but that she still has not gotten over his death. She feels lonely and is finding it difficult to motivate herself to prepare adequate meals for only one person.
• She also reports experiencing nausea and some difficulty chewing over the past month.
• You take a closer look in her mouth and notice that her dentures are loose and that there are a few small ulcers on her hard palate.
Plan• In an attempt to address her risk factors, you advise her to
have her dentures adjusted. Suspecting that the NSAIDS may be contributing to her nausea, you advise her to use acetaminophen for her knee pains instead. At your encouragement, she starts attending grief counseling and becomes involved in social activities, including a supper club, at her local seniors centre.
• Over the next two months, her appetite improves and she gains 4#.
• Her weight loss appears to have been the result of multiple factors, including social isolation, bereavement, chewing issues, decreased oral intake and possibly the use of NSAIDs.
• Risk factor modification appears to have been successful so you do not consider further nutritional or pharmacologic interventions at this time.