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