TheRubins.com

Undernourishment in the Elderly: Part I

(6/11/15)-

Studies and Reports

We received the following e-mail from Roseanna Wheeler, for which we thank her for taking the time to correct our error, and point out the site she is associated with: We apologize to her for erroneously sending her a wrong e-mail. Take a look at her site, and decide for yourself:

“ Roseanna Wheeler <info@restaurantsupplyresearch.com> wrote:

 Hi Harold,

I do research for Katom.com, a website on food equipment, and the  commercial food industry.. My name is Roseanna Wheeler.


I am trying to get a hold of the person responsible for the above page.
There is a link on the page with the anchor text:
http://www.nursinghomeabuseresourcecenter.com/injured/malnutrition that is not working.

We have worked very hard to put together a complete resource on the USDA's My Plate that we think is now the best on the internet.
https://www.katom.com/learning-center/myplate-resource-guide.html

It contains everything from technical understanding of My Plate, a historical comparison of past USDA recommended programs including the Food Pyramid, commentary and analysis of the programs, and we believe is the

best starting point on the internet for research in this area.

We are updating it regularly to keep it very current.

I would love you to consider placing a link on your page to

https://www.katom.com/learning-center/myplate-resource-guide.html
.

Many food professionals, researchers and families could be helped by having this info.

Thank You So Much!
Roseanna Wheeler

info@restaurantsupplyresearch.com


2248 Meridian Blvd., Suite H
Minden NV 89423

The following is the old item that Roseanna Wheeler was referring to with an broken link that, thanks to her, has been deleted- “According to a report on Nursing Home Residents Legal Center web site: "Government statistics show that 47% of residents in nursing homes need assistance with eating. 21% of the residents are completely dependent for help." The University of Oklahoma Health Sciences Center report by Dr. Sayed Rahman states "Studies of hospitalized elderly have confirmed that a loss of 10% of body weight is associated with increased mortality while a period of stable weight strongly suggests that a 6 month survival is probable." McWhirter et. al. found that, in the United Kingdom, the prevalence of undernourishment on admission to hospital is 40%. A UC San Francisco study of nursing home residents with eating problems found that inadequate staffing, lack of attention to food preferences and medical problems all were factors in why people weren't eating”

General Information

(7/15/05)- The US Department of Health and Human Services (HHS) has released the "Dietary Guidelines for Americans 2005", which promotes healthy habits and reducing the risk of chronic disease through nutrition and physical activity. The guidelines and brochure are available on line at http://www.health.gov/dietaryguidelines  Thanks to Kelly Coleman for emailing us with the corrected address:

(4/30/02)Undernutrition, due to insufficient intake of food or lack of quality of food eaten, is a not uncommon problem in the elderly. This is not to be confused with reduced calorie intake that some studies associate with prolonging life.

Undernourishment is a serious, potentially life-threatening situation in the elderly. The figures, according to Silver, range from 5% to 12% of the community dwelling elderly, 30% to 61% of hospitalized elderly, and 40% to 85% in those living in long-term care institutions. When using a figure of ten percent underweight from the Metropolitan Life Insurance index of weights, individuals over 75 show a 40% rate of underweight.

Calle and colleagues, in a study reported in the NEJM, showed that the lower the body mass index (BMI), the greater the mortality rate. This has to be balanced with the concept that studies of older adults have shown that a physiological change causing a linear decrease in food intake occurs with increasing age. (Morley JE. Anorexia in Aging: physiologic and pathogenic. Am J Clin Nut 1997; 66: 760-773.) 

Introduction

The contributors to underweight causes are multifactorial. This article will not explore the socio-economic factors that may contribute to this problem. Well–developed (first world) nations appear to have some fail-safe programs for elderly in need to get food i. e. meals on wheels, senior center feeding programs, food stamps etc.

These programs have qualifying standards/procedures that may scare off elderly people eligible for the programs. There have been no reports of emergency rooms swamped with individuals who show extreme symptoms of starvation, despite occasional reports of elderly eating dog or cat food or "starving" children/adults that may be due to specific situations. There are frequent reports of elderly who are undernourished as result of medical conditions, dementia or other confused states. This article will look at the medical causes of undernourishment and attempt to show what the medical research literature is trying to do about this condition.

Studies and Reports

We received the following e-mail from Roseanna Wheeler, for which we thank her for taking the time to correct our error, and point out the site she is associated with:

“ Roseanna Wheeler <info@restaurantsupplyresearch.com> wrote:

 Hi Harold,

I do research for Katom.com, a website on food equipment, and the  commercial food industry.. My name is Roseanna Wheeler.


I am trying to get a hold of the person responsible for the above page.
There is a link on the page with the anchor text: http://www.nursinghomeabuseresourcecenter.com/injured/malnutrition
that is not working.

We have worked very hard to put together a complete resource on the USDA's My Plate that we think is now the best on the internet.
https://www.katom.com/learning-center/myplate-resource-guide.html

It contains everything from technical understanding of My Plate, a historical comparison of past USDA recommended programs including the Food Pyramid, commentary and analysis of the programs, and we believe is the

best starting point on the internet for research in this area.

We are updating it regularly to keep it very current.

I would love you to consider placing a link on your page to
https://www.katom.com/learning-center/myplate-resource-guide.html
.

Many food professionals, researchers and families could be helped by having this info.

Thank You So Much!
Roseanna Wheeler
info@restaurantsupplyresearch.com


2248 Meridian Blvd., Suite H
Minden NV 89423

According to a report on Nursing Home Residents Legal Center web site (http://www.nursinghomeabuseresourcecenter.com/injured/malnutrition) "Government statistics show that 47% of residents in nursing homes need assistance with eating. 21% of the residents are completely dependent for help." The University of Oklahoma Health Sciences Center report by Dr. Sayed Rahman states "Studies of hospitalized elderly have confirmed that a loss of 10% of body weight is associated with increased mortality while a period of stable weight strongly suggests that a 6 month survival is probable." McWhirter et. al. found that, in the United Kingdom, the prevalence of undernourishment on admission to hospital is 40%. A UC San Francisco study of nursing home residents with eating problems found that inadequate staffing, lack of attention to food preferences and medical problems all were factors in why people weren't eating.

Undernourishment and Federal Action

The federal Department of Health and Human Services in 1999 instituted new guidelines that dictate how nursing home investigators should evaluate weight loss, malnutrition and dehydration. They must review nursing home records (which must include any weight loss of 5% within 30 days or 10% within six months), interview health professionals and family members and personally observe at least two meals. UCLA aging researchers have found in several related studies that about seven out of 10 nursing home residents fail to finish 75% of their food--the federal government's yardstick for measuring the risk of malnutrition. Caretakers or family members can ask to see "care plans" for the resident which are supposed to deal with any weight loss and also have staff check the weight of the resident of nursing homes.

Nursing Home Record Keeping and Undernourishment

Although nursing homes are required to keep records of how much residents eat and drink and to track their weight, it is difficult for researchers to determine how often inadequate food and fluids play a role in their deaths. Death certificates rarely cite dehydration or excessive weight loss. Tracking of amount eaten is a very difficult task. In my over four years of visiting nursing homes, from New England, Florida, and in the Southwest, I spent extended time with residents at lunch and dinnertime.

I never saw anyone weigh the food left over, nor continually observing the amount eaten on a consistent basis unless a loved one specifically requested that this be don. Dieticians do spend time in the dining room and observe the amount eaten by a resident. They often have to observe a number of people and do not see residents exchange food, or spill food on to other trays or on the floor, so the accuracy of their observations is highly questionable.

While nursing assistants typically feed from five to 20 people in about an hour, UCLA researchers found that it takes an average of 40 minutes for just one nursing home resident to finish a meal. The typical scene in a nursing home is a resident waiting at their table for extended periods of time to get their meals, being asked to eat quickly and then ushered out of the dining room before completing the meal. Some learn to eat quickly or pocket fruit, crackers etc. to be taken back to their room. Most never finish their meal, nor completely drink the nutritional supplement ordered by the dietician.

Nursing professor Jeanie Kayser-Jones of UCSF observed 100 residents of nursing homes in the Pacific Northwest. Among her observations:

--"Nursing home workers often were so rushed that they "shoveled" food into residents' mouths, causing choking and coughing.

--The food, while healthful, was sometimes served in unappetizing form: doled out in indistinguishable scoopfuls or pureed and mixed into a glass of milk.

--Food trays often were untouched by residents, and nutritional supplements weren't consumed.

--Nurse assistants placed water pitchers out of reach or failed to open drink containers for residents with arthritic hands.

--Only one of 40 residents whose food and fluid intake she analyzed received the minimum fluid requirement (at least six glasses daily).

--Some residents went without liquids for as long as 24 hours, (according to Kayser-Jones), and some nursing assistants avoided giving liquids to incontinent residents so that they wouldn't have to change clothes and bedding as often."

Under these conditions, it is not hard to see that undernourishment can be a big problem.

Further Studies

Simply providing three square meals a day to an elderly resident doesn't mean the meals are eaten. That's because the reasons someone won't eat can be complex. UCLA aging researchers have found in several related studies that about seven out of 10 nursing home residents fail to finish 75% of their food--the federal government's yardstick for measuring the risk of malnutrition.

The researchers from UCLA's Borun Center on Aging tried to encourage poor eaters by sitting with them at meals for extended periods over several days. Sometimes they would even place the food on a fork for the nursing home residents. Even so, only about half ate more than they had before, said Sandra Simmons, lead author of a study on feeding assistance. "The picture is more complex than people think," Simmons said.

The findings suggest that inadequate staffing or poor quality care are not the only explanations for why some elderly patients won't eat, said Jack Schnelle, the Borun Center's director. Even when the staff uses charm or persuasion to get older patients to eat, sometimes people "just don't want the food." This symptom needs to be addressed by the staff in a different manner than is in operation at this time. Specific intervention techniques would seem in order that can target this issue. It would call for a multidisciplinary approach because of the multifactorial nature of the problem, not just making nutritional adjustments to the individual’s diet or ordering some nutrient supplement to be taken by the resident.

Rahman in his study of ambulatory geriatric patients (mean age of 76.8 years), concluded that "Undernourished seniors had the following characteristics: they were more likely to be female, be depressed, have lower educational levels, did not wear dentures, received no help in meal preparation, were taking a large number of medications and were less likely to follow up with medical care.

There was also a significant correlation of decreased functional and mental status with undernourishment and lower scores on the General and Perceived Health Scales of the Duke Health Profile." What he did not mention was that the aging process itself can dull one's sense of taste or hunger.

Other reasons for undernourishment include illness and disability as well as a dislike of institutional food. At greatest risk are frail seniors who must take multiple medications daily--some known to be appetite-killers (see below). These people tend to have trouble seeing, hearing and tasting, as well as swallowing and chewing. They are vulnerable to depression and prone to forgetfulness and declining mobility. About half of them have dementia, which requires extra care during mealtime. Introduction of an eating specialist may preempt this problem and save lives.

The range of nutritional deficiency is broad with an apparent lack of large national studies and no consensus on what health measures should be used. Based on observation, no matter the measure, the problem exists even at some of the "best"--or costliest--facilities

Depression and Undernourishment

Medically, a major symptom of depression is weight loss. Wilson and his group reported that 30% of older medical outpatients had depression and weight loss. Morley et. al.'s study indicated that depression is the most common cause of weight loss in nursing home residents. Depression is a treatable disease, and successful treatment has resulted in weight gain. However, first-onset depression in the elderly may be more complicated etiologically than the general population depression. Gastointestinal hormones, especially cholecystokinin (CCK), gastrin-releasing peptide and somatostatin, regulate how satiated an individual feels when eating. Monitoring of some of these levels could be a red light for undernourishment and could be followed with appropriate treatment, not only of the depression but the elevated levels of the hormone.

Medication and Undernourishment

Many of the medications commonly prescribed to residents of nursing homes have adverse effects related to anorexia. The following list can be used as a guideline to monitor potential undereating. It is taken from a number of sources including ASCP Report, Guide to Preferred Drugs in Long Term Care, RxList and Clinical Pharmacology OnLine. Not all individuals taking these medications will have the adverse effect. A difficulty with the elderly is that many are taking multi-medications and they may have synergistic effects resulting in killing of appetite. Medical staff needs to be consulted, looking at the entire spectrum of reasons for weight loss and give weight to the potential negative effect that these medications can have on nourishment..

Potential Adverse Drug Effects on Nourishment

Generic Name

Brand Name

Amlodipine

Norvasc

Ciprofloxacin

Cipro

Cisapride

Propulsid

Conjugated estrogen

Premarin

Digoxin

Lanoxin

Enalapril maleate

Vasotec

Famotidine

Pepcid

Fentanyl transderm

Duragesic

Furosamide

Lasix

Ipratropium bromide

Atrovent

Levothyroxine sodium

Synthroid

Narcotic analgesic

Propacet

Nifedipine

Procardia XL

Nizatidine

Axid

Omerprazole

Prilosec

Paroxetine

Paxil

Phenytoin

Dilantin

Potassium replacement

K-Dur

Ranitidine HCL

Zantac

Sertraline HCL

Zoloft

Warfarin

Coumadine

 

Infections and Undernourishment

Two common infections in the elderly are upper respiratory infections (URIs) and urinary tract infections (UTIs). According to Rudman and Fellar, 15% to 20% of older persons suffer undernourishment due to both acute and chronic infections. This may be due to a negative nitrogen balance.

A positive nitrogen balance assures that the amount of protein being administered is sufficient to cover the losses of endogenous protein occurring secondary to catabolism. Once positive balance is achieved, protein replacement has been optimized. The urinary urea nitrogen test is used to determine a patient's nitrogen balance. If the urinary nitrogen balance is positive, the patient is ingesting sufficient protein and nitrogen is excreted in the urine.

A urinary urea nitrogen value less than zero indicates a negative nitrogen balance, which is an indication that the patient needs a higher protein intake. When urinary urea nitrogen and nitrogen balance are assessed, the dietician does a protein intake assessment and the nurse is responsible for accurately recording all food intakes during the 24 hours of the test period.

Normal urinary urea nitrogen ranges between 6 and 17 gm in a 24-hour period. The value or urea nitrogen then can alert the staff to a potential undernourishment problem. Measures to counteract this undernourishment can be initiated to prevent serious medical problems. The difficulty arises when the patient refuses to eat and someone must spend time cajoling the patient to eat. Food, especially the kind given on special diets can be bland and monotonous, especially when fat is left out. Combine this with alteration in taste that happens as we get older and one can see the magnitude of this problem. Undernourishment may be a consequence of the treatment.

Cancer and Undernourishment

Cancer and its treatment are the most obvious reason for weight loss. Anorexia is defined as a lack or severe loss of appetite. Many cancer patients develop anorexia as a result of their disease process or as a result of a specific treatment for their disease. Many cancer patients experience overwhelming fatigue, lassitude, and generalized weakness (asthenia).

Again, like anorexia, this can be due to the disease itself, or secondary to treatment such as radiation, medicines, or chemotherapy. The actual state of malnutrition and wasting that results from anorexia is called cachexia. Decrease in body weight is characterized by significant loss of both adipose tissue and muscle mass that makes weight gain especially difficult for patients with progressive cancer. Cachexia can also be related to the disease itself or the effects of treatment.

Treatment of this situation is problematic. Nutritional counseling is of course recommended and usually consists of eating frequently, small meals, avoiding spicy foods, eat more in the morning, avoid cooking aromas etc. Certain appetite stimulants may be prescribed, but many have their side effects when chronically administered.

Examples of these stimulants include progestational agents (megestrol acetate, medr-oxygesterone), corticosteroids (dexamethasone), and such unproven drugs as dronbinol (Marinol), branched-chain amino acids, metoclopramide and eicosapentaenoic acid. The literature is replete with pilot studies of helpful drugs for cachexia and hopefully new information will come available to deal with this life-threatening symptom.

Presently, as we understand the literature, no drug has long-term positive effects on this symptom, though they may provide temporary relief. However, they appear reasonable to try. The question remains whether a person can be "forced " to eat and also the indications that in cancer the nutrients may provide stimulus for cancer growth compound the solution for this condition.

Dementia and Undernourishment

In dementia, the individual may not recognize the need to eat. Also, there is a symptom called apraxia for swallowing, where the demented individual needs to be reminded to swallow when eating. There are reports in the literature, without any scientific corroboration, that Alzheimer’s disease patients have a faster metabolism, which could contribute to undernourishment. These factors make it essential to monitor weigh in demented patients.

Treatment of various symptoms may help deal with the undernourishment i. e. depression. Meal times need to be free of extraneous stimulation, regularly scheduled, and need to last longer than the normal time spent eating. It takes a lot of patience on the part of the caretaker, as well as creative approaches, similar to child feeding to deal with this issue in demented patients.

Clinical Evaluations of Protein-Caloric Undernourishment

When evaluating for protein-caloric undernourishment, the physician looks for a number of signs as clues for a diagnosis. The obvious clue is loss of weight. Other signs are muscle wasting including temporalis muscle, calf muscle and the muscle between thumb and index finger. Further indication would include subcutaneous loss of fat, sparse, dull hair, orthostasis, edema, poor wound healing, decreased food intake, weak cough, decreased grip strength, change in pallor, parotidmegaly, and cognitive impairment. Biochemical tests are not specific in identifying undernutrition.

Galanos et. al. suggest use of BMI (weight in kilograms divided by height in meters squared) as an indicator of nutritional and mortality risk. The suggested numbers are BMI below 19 in men and below 19.4 in women as a definition of undernutrition. (In the study by Rahman mentioned above, a BMI of less than 22 was used.)

We understand that some physicians use a graded assessment to diagnose undernourishment. It may prove helpful that this become a standard part of any evaluation of individuals in nursing homes. The graded assessment is a gross measure and it is probable that some action needs to be taken when rating is at grade B or grade C.

Grade A: minimal or no changes in food intake, improving body weight and minimal change in function

Grade B: There is evidence of food restriction and functional changes but minimal weight change.

Grade C: There are changes in dietary intake and body mass (greater than 10% weight change over last 6 months) and poor functional status.

White et al reported on a nutrition screening initiative, which is felt to predict individuals at risk for developing undernourishment. See J Am Diet Assoc. 1992; 92:163 for further explanation of this screening device.

Recently, the American Dietetic Association has introduced a Nutrition Screening Instrument (NSI) developed by 37 expert consensus panel that is undergoing research evaluation.

Please also see: Proper Nutrition and the Elderly-Part II  

 

REFERENCES

  1. Dwyer J., Gallo J., Reichel W. Assessing nutritional status in elderly patients. American Family Physician 1993; 47:614.
  2. Galanos AN, Pieper CF, Kussin PS, et al Relationship of body mass index to subsequent mortality among seriously ill hospitalized patients. Crit Care Med 1997; 25:1962.
  3. University of Oklahoma Science Center, Oklahoma City, OK report of study by Rahman, Sayad. Impaired Nutritional Status in Geriatric Population. No date.
  4. McWhirter J., Pennington C. Incidence and recognition of malnutrition in hospital. BJM 1994; 308:
  5. Rudman D., Fellar AG. Protein-calorie undernutrition in nursing home. J Am Geriatr Soc 1989; 37:173.
  6. Silver AJ. Malnutrition. In: Beck JC, ed. Geriatrics Review Syllabus. A Core Curriculum in Geriatric Medicine. Book1/Syllabus and Questions. New York: American Geriatrics Society, 1991
  7. Thomas DR., Morley JE. Nutritional Assessment and Indicators of Undernutrition in the Elderly. Resident & Staff Physician. 2002; 48:47-55.
  8. White JV., Dwyer JT., Posner BM et al. Nutrition screening initiative: development and implementation of the public awareness checklist and screening tools. J Am Diet Assoc. 1992; 92:163

 

FOR AN INFORMATIVE AND PERSONAL ARTICLE ON PRACTICAL SUGGESTIONS WHEN SELECTING A NURSING HOME SEE OUR ARTICLE
"How to Select a Nursing Home"

by Harold Rubin, MS, ABD, CRC, Guest Lecturer
updated June 11, 2015

e-mail: hrubin12@nyc.rr.com or allanrubin4@gmail.com  

http://www.therubins.com

TheRubins.com

 

 

.