nutritional disorders in chronic diseases
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Nutritional Disorders in Chronic diseaseTRANSCRIPT
Nutritional Disorders in Chronic Illness
MARC EVANS M. ABAT, MD, FPCP, FPCGM
Head, Center for Healthy Aging, The Medical City
Clinical Associate Professor, Section of Adult Medicine, Department of Medicine, Philippine General Hospital
Visiting Consultant, Geriatric Center, St. Luke’s Medical Center
Visiting Consultant, Department of Medicine, Manila Doctors Hospital
Infirmary Geriatrician-Jesuit Healthcare System
Case
• 80 year old female
• Severely demented, diabetic, hypertensive, hyperuricemic, with stage 4 chronic kidney disease from diabetic nephropathy
• History of fragility fracture on left upper humerus
• 3 episodes of pneumonia in the last 8 months
• Frequent episodes of abdominal bloating with frequent watery stools
• Fed with blenderized food 4x a day per orem, about 1½ cups per feeding; components variable
• Actual consumption of feeding: about 70-80% according to the caregiver
• Has about 15 medications, including calcium carbonate, ferrous sulfate, amlodipine, metformin, oral rivastigmine and bisacodyl
• Actual body weight 38 kg, measured height 151 cm
• (+)angular cheilitis and oral ulcers
• (+)oral thrush
• Distended and tympanitic abdomen
• (+)grade II pressure ulceration on sacral area
Which of the following contributes to possible
malnutrition in this patient?
A. Dementia
B. Chronic kidney disease
C. Dysphagia
D. Constipation
E. Calcium carbonate
F. Blenderized feeding
G. Lack of vitamin supplementation
All of them!!
Outline
• Prevalence
• Approaching Nutritional Disorders
– Calories and Nutrients
– Hurdles along the Nutrition Pathway
• Management
Prevalence
• 181 subjects (98 women) aged 65 or older• the majority of subjects had a normal Body Mass
Index (BMI),• 18.0% were underweight and 37.3% were
overweight• 16.0% and 26.0% subjects had muscle wasting as
assessed by low mid upper arm circumference (MUAC) and calf circumference (CC)
• 41.4% subjects had hypoalbuminemia, 39.4% had anemia, and 23.4% had low total lymphocyte count.
Health and the Environment Journal, 2010, Vol. 1, No. 2
Nutr Clin Pract 2010 25: 548
Consequences
• Increased morbidity and mortality
– Pneumonia
– Pressure ulceration
• Increased rates of readmission
• Increased rates of institutionalization
• Increased length of hospital stay
• Increased cost of care
Nutr Clin Pract 2010 25: 548
Calories
MacronutrientsMicronutrients
Not too easy to
hit!!
Dilemmas
• Calories– How much to actually give
– Guides to base caloric estimation
• Macronutrients– Disease
– Multiple co-morbiditiesdifficulty in striking a balance
• Micronutrients– Disease
– Not all can be measured
– Not all have obvious clinical signs of deficiency or toxicity
Cognition and Behavior for eatingRecognition of hunger and when to eatRecognition of what to eatAppreciation of the foodAbility to actually prepare food or communicate this to caregiver
DementiaVegetative/Comatose
statesStroke
Drugs that can cause ANOREXIA
• digoxin
• phenytoin
• SSRI’s / lithium
• Ca++ channel blockers
• H2 receptor antagonists / PPIs
• Any chemotherapy
• metronidazole
• narcotic analgesics
• K+ supplements
• furosemide
• ipratropium bromide
• theophylline
• spironolactone
• levodopa
• fluoxetine
Senses for eatingUnderlies appreciation of the food being eatenIncludes predominant senses of sight, smell and tastePhysiologic changes with aging + pathologic changes with disease can affect overall appreciation of food
Physiologic decline in taste, smell and sight
DementiaVegetative/Comatose states
StrokeAcute diseaseMedications
Drugs can interfere with senses of taste and smell
• More than 250 medications reportedly disturb gustatory sensation
• More than 40 drugs reportedly disturb the sense of olfaction
• A few of these agents have been objectively determined to affect these functions via experiments, clinical trials, or intensity scaling
Drugs That Interfere With Gustation (taste) and Olfaction (smell)
Gustation• Allopurinol• Amitriptyline• Ampicillin• Baclofen• Dexamethasone• Diltiazem• Enalapril• Hydrochlorothiazide • Imipramine• Labetalol• Mexiletine• Ofloxacin• Nifedipine• Phenytoin• Promethazine• Propranolol• Sulfamethoxazole• Tetracyclines
Olfaction • Amitriptyline• Codeine• Dexamethasone• Enalapril• Flunisolide• Flurbiprofen• Hydromorphone• Levamisole• Morphine• Pentamidine• Propafenone
Chewing and SwallowingDysphagiaCognitiveNeurologicMuscularDental
Remains poorly recognized and diagnosed
Age-related deterioration in dentition and muscle strength
DementiaVegetative/Comatose states
Stroke, neuropathies and other neurological conditionsDietary considerations
Stages of Swallowing
• Oral– Weak tongue and jaw muscles– Uncoordinated movement– No movement
• Pharyngeal– Weakness or paresis of muscles– Uncoordinated movements
• Esophageal– Weak peristaltic movements– Esophageal spasms
• Primary condition• Secondary to pain (e.g. in reflux esophagitis or ulceration)
Dysphagia Prevalence
• As much as 15% in the elderly population
• As much as 37.6% in community-dwelling elderly
Clinical Interventions in Aging 2012:7 287
Movement and Digestion of FoodPhysiologic changes with agingDecreased rate of epithelializationDecreased gastric complianceDecreased peristalsis resulting in increased intestinal transitChanges in digestive enzyme secretion
Superimposed pathologic and pharmacologic effects
• Obstruction of GI tract– Malignancies
• Impairments in mucosal integrity and function– Atrophic gastritispernicious anemia– Lactose intolerance
• Deficiencies in digestive enzyme secretion– Chronic pancreatitis– s/p cholecystectomy
• Altered gastric motility– Diabetic gastroparesis– Chronic constipation and fecal impaction– Drug effects (e.g. morphine, calcium channel blockers)
• Altered gastrointestinal capacitance and transit– Gastrointestinal reconstruction (e.g. bariatric surgery or
Roux-en-Y procedures)
Nutrient AbsorptionDefects may be preceded by problems in digestionMay be complicated by structural GI changesChanges in transit timeChanges in absorptive surfaces
Pernicious anemiaPost-surgical states (e.g.
colectomy, bariatric surgery, short bowel syndrome)
Drug effects
Drug-nutrient interactions
• Many of the aforementioned drugs and others interfere with the absorption of various vitamins and minerals
• Examples:
Antacids- Vitamin B12, folate, iron, total kcal
Diuretics- Zn, Mg, Vitamin B6, K+, Cu
Laxatives- Ca, Vitamins A, B2, B12, D, E, K
Drug-Nutrient Interaction
Drug Reduced Nutrient Availability
Alcohol Zinc, vitamins A, B1, B2, B6, folate, vitamin B12
Antacids Vitamin B12, folate, iron, total kcal
Antibiotics, broad-spectrum Vitamin K
Digoxin Zinc, total kcal (via anorexia)
Diuretics Zinc, magnesium, vitamin B6, potassium, copper
Laxatives Calcium, vitamins A, B2, B12, D, E, K
Lipid-binding resins Vitamins A, D, E, K
Metformin Vitamin B12, total kcal
Phenytoin/Salicylates Vitamin D, folate/Vitamin C, folate
SSRIs Total kcal (via anorexia)
Trimethoprim Folate
Overall Nutrient MetabolismRelated to my physiologic changesKidneysLiverChanges in body fat and water percentages
Chronic disease necessitating dietary modification Altered nutrient utilization as a result of disease states
Dietary Modifications in Chronic Illnesses
• Non-dialyzed chronic kidney disease– Protein requirement: as low as 0.6g/kg of protein
– Low potassium, low phosphorus, low purine
• COPD patients– Low carbohydrate diets previously ordered
– Calories directly related to carbon dioxide output vs. high-energy expenditure state
• Liver cirrhosis– Low protein diets, branched chain amino acids
Management
• comprehensive geriatric management
• an interdisciplinary approach
• multimodality interventions
Comprehensive Geriatric Examination
• Detailed History
• Physical and Neurological Examination
• Cognitive Evaluation
• Behavioral/Emotional Evaluation
• Functional Evaluation
• Environmental Evaluation
• Social Evaluation
• Physical manifestations of nutrient deficiencies in the older patient may be difficult to detect (particularly vitamin deficiencies)
• Deficiencies usually occur in combination (both as caloric, macro and micronutrient deficiencies)
• Toxicities may be even more difficult to detect
Diagnostics
• CBC• FBS, kidney, liver and thyroid function tests• Albumin (interpreted cautiously)• Lipid profile• Urinalysis• 12-L ECG, CXR, 2D-echo• Fecalysis• Inflammatory markers?• Vitamin assays?• Calorimetry?• Other specialized tests?
Interdisciplinary Approach
• Primary physician/s (Geriatrician, Internist, Family Physician, Others)
• Neurologists• ENT specialists• Gastroenterologists, Surgeons• Physiatrist• Physical, Occupational, Speech and Swallowing
Therapists• Nurses• Nutritionist• Pharmacist
Multimodality Interventions
• Medical interventions
• Drug reviews and monitoring
• Nutritional Management
• Physical, Occupational, Swallowing and Speech Therapy
• Artificial Enteral Feeding
• Parenteral Feeding???
Nutritional Management
• Dietary Prescription
– Tolerance
– Adequacy of prescription and response
• Use of nutritional supplements
– Tolerance
– Cost vs. benefit
Therapy
• Individualized approach
• Challenges
– Assessment
– Intervention application
– Response and limitations
Artificial Enteral Feeding
• Nasogastric feeding
• Gastrostomy (PEG or surgical)
• Enterostomy
Summary
• Nutritional disorders are common in chronic disease
• Aside from viewing nutritional disorders as those affecting calorie, macronutrient and micronutrient intake, it can be viewed as to the level along the nutrition pathway at which these develop
• Medications play a significant part in nutritional disorders
• Comprehensive geriatric management, an interdisciplinary approach with multimodality interventions are needed