CONSIDER: NUTRITION IN THE ELDERLY
Overview:
- Weight loss is an important indicator of malnutrition and is common in the elderly.
- A loss of 10 lbs over a six-month period whether intentional or unintentional is a critical indicator for further assessment.
- 1,3 Both voluntary and involuntary weight loss in the elderly is associated with increased morbidity and mortality
- The causes of unintentional weight loss are multi-faceted and treatment modalities include nonpharmacologic and pharmacologic interventions aimed at trying to treat the unintentional weight loss.
Definitions:
Unintentional weight loss: an involuntary loss in total body weight over time. Unintentional weight loss is associated with disease severity or undiagnosed illness.
Long-term unintentional weight loss: a loss of either 5 kg or more or 5% of usual body weight over a 5-10 year period.
Acute unintentional weight loss: the unintentional loss of total body weight of > 7.5% of baseline body weight within a 6-month period.1
Assessment/Screening Tools:
Assessment
To assess over all nutrition status and potential triggers for weight loss in the elderly, the Mini-Nutrition Assessment should be used.
- Complete a weight history, it’s important to:
- Note the patient’s usual body weight.
- Obtain history of weight loss, including whether the weight loss was intentional or unintentional.
- Note the time period the weight loss occurred.
- Obtain an accurate weight and height.
- Once a weight is obtained, Body Mass Index (BMI) should be calculated as follows: weight in kg/ (height in meters2). Normal BMI in the elderly is 22 to 27.4
- Review prescribed and over-the-counter medications – many drugs can have anorexic properties. (See Table 1)
Causes of Weight Loss
While approximately 10-36% of patients with unintentional weight loss have an unknown etiology, the common causes of unintentional weight loss in the elderly (from most to least frequently occurring) include: 1
- Malignant disease
- Psychiatric disorders (especially depression)
- Gastrointestinal disease
- Endocrine disorders (especially hyperthyroidism, new onset or out of control diabetes)
- Cardiovascular disease
- Nutritional disorders
- Alcoholism
- Respiratory disease
- Neurologic disorders
- Chronic infection
- Renal disease
- Connective tissue diseases
- Drug-induced weight loss (medication side effects)
The mnemonic "Meals on Wheels" can be used to categorize the common treatable causes of unintentional weight loss in the elderly.
"Meals on Wheels"
M Medication effects
E Emotional problems, especially depression
A Anorexia tardive (nervosa), alcoholism
L Late-life paranoia S Swallowing disorders
O Oral factors (poor fitting dentures, cavities)
N No money
W Wandering and other dementia-related behaviors
H Hyperthyroidism, hypothyroidism, hyperparathyroidism, hypoadrenalism
E Enteric problems (e.g. malabsorption) E Eating problems (e.g. inability to feed self)
L Low-salt, low cholesterol diets
S Social problems (e.g. isolation, inability to obtained preferred foods), gallstones
Source: Morley JE, Silver AJ. (1995). Nutritional issues in nursing home care. Annals of Internal Medicine, 123 (11): 850-9. With permission from the publisher.
Care Strategies
- The primary medical treatment of unintentional weight loss is to identify the cause of the weight loss. Nursing's primary care strategy should be aimed at preventing further weight loss.6 An interdisciplinary approach should be utilized to increase food intake in older patients with unintentional weight loss.
- Specific nutritional interventions need to be individualized and focus on:1,6
- removal of dietary restrictions
- adding flavor enhancers
- provision of small frequent servings
- unlimited intake of favorite foods
- oral nutritional supplements administered between meals and no more than one hour before meals
- When indicated, specialized nutritional support should be utilized if the patient can’t, shouldn’t or won’t eat adequately and if the benefits of improved nutrition outweigh the associated risks.7 (See guidelines from American Society of Parenteral/Enteral Nutrition).
- Non-nutrition interventions should focus on physical exercise and increased activity when appropriate.6 Exercise can help to increase appetite.
- Pharmacological therapy with the use of orexigenic drugs may be instituted when attempts at weight gain have not been successful. The most commonly used appetite stimulants are mirtazapine (Remeron), dronabinol (Marinol) and megestrol acetate (Megace Oral Suspension).8 Before initiating orexigenic medications consider risk versus benefit (e.g., risk: side effect somnolence) 5 http://www.ltcnutrition.org/pdf/OrexigenicDrugs.pdf
- Discuss prognosis, goals and objectives, aspiration risk if present. Always address advance directives/wishes related to artificial nutrition and hydration.8
- Interdisciplinary assessment, plan, and follow-up of unintentional weight loss including: registered dietician, nursing, speech therapy, physical and/or occupational therapy, speech therapy, primary medical provider and mental health clinician.
- Unavoidable weight loss should be documented on medical problem list and care plan (e.g. end stage illness or terminal condition).
- Discontinue/change medications that cause anorexia, or other symptoms that inhibit nutrition: lethargy, weakness, confusion, and change in taste or salivation, or cause nausea.8,5
References
1. Alibhai, S.M.H., Greenwood, C., & Payette, H. (2005). An approach to the management of unintentional weight loss in elderly people. Canadian Medical Association Journal, 172, 773-780.
2. Council for Nutritional Clinical Strategies in Long-term Care. (2004). Weight loss: A vital sign of undernutrition in long-term care. http://www.ltcnutrition.org
3. Institute of Medicine. (2000). The role of nutrition in maintaining the nation’s elderly: Evaluating coverage of nutritional services for the Medicare population. Washington, DC: National Academies Press.
4. Nutrition Screening Initiative. (2002). Nutrition Statement of Principle. Retrieved September 1, 2005 at http://www.eatright.org/Public/Files/nutrition(1).pdf.
5. Morley, JE, Thomas, DR. (June 2004). CME: Update: Guidelines for the use of orexigenic drugs in long-term care. Annals of Long-Term Care, Supp1, 1-10.
6. Huffman, G. B. (2002). Evaluating and treating unintentional weight loss in the elderly. American Family Physician, 65, 640-650.
7. American Society for Parenteral and Enteral Nutrition. (2002). Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. Journal of Parenteral and Enteral Nutrition, 26 (1 Supplement), 1SA-138SA.
8. Thomas DR, Ashmen, W, Morley JE, Evans WJ. (2000). Nutritional Management in long-term care: development of a clinical guideline. Council for Nutritional strategies in Long-Term Care. Journal Gerontological and Biological Science Med Sci., 55(12) M725-34.
Last updated - January 2006
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