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Nutritional disorders in chronic diseases
This document discusses nutritional disorders that are common in patients with chronic illness. It notes that malnutrition can result from problems at different stages of the nutrition pathway, including cognition/behavior, senses, chewing/swallowing, digestion, absorption, and nutrient metabolism. Common chronic conditions like dementia, kidney disease, and constipation can all contribute to poor nutrition. An interdisciplinary approach is needed to properly assess, diagnose, and manage nutritional disorders through medical, dietary, and rehabilitation interventions.
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Nutritional disorders in chronic diseases
- 1. Nutritional Disorders inChronic 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
- 2. Case • 80year 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
- 3. • Fed withblenderized 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
- 4. • Actual bodyweight 38 kg, measured height 151 cm • (+)angular cheilitis and oral ulcers • (+)oral thrush • Distended and tympanitic abdomen • (+)grade II pressure ulceration on sacral area
- 5. Which of thefollowing 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 All of them!! supplementation
- 6. Outline • Prevalence • Approaching Nutritional Disorders – Calories and Nutrients – Hurdles along the Nutrition Pathway • Management
- 7. Prevalence • 181subjects (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
- 8. Nutr Clin Pract2010 25: 548
- 9. Consequences • Increasedmorbidity 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
- 10. Calories Not too easy to hit!! Micronutrients Macronutrients
- 11. 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
- 12. Cognition and Behaviorfor eating Recognition of hunger and when to eat Recognition of what to eat Appreciation of the food Ability to actually prepare food or communicate this to caregiver Dementia Vegetative/Comatose states Stroke
- 13. Drugs that cancause 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
- 14. Senses for eating Underlies appreciation of the food being eaten Includes predominant senses of sight, smell and taste Physiologic changes with aging + pathologic changes with disease can affect overall appreciation of food Physiologic decline in taste, smell and sight Dementia Vegetative/Comatose states Stroke Acute disease Medications
- 15. Drugs can interferewith 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
- 16. Drugs That InterfereWith 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
- 17. Chewing and Swallowing Dysphagia Cognitive Neurologic Muscular Dental Remains poorly recognized and diagnosed Age-related deterioration in dentition and muscle strength Dementia Vegetative/Comatose states Stroke, neuropathies and other neurological conditions Dietary considerations
- 18. 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)
- 19. 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
- 20. Movement and Digestionof Food Physiologic changes with aging Decreased rate of epithelialization Decreased gastric compliance Decreased peristalsis resulting in increased intestinal transit Changes in digestive enzyme secretion Superimposed pathologic and pharmacologic effects
- 21. • Obstruction ofGI 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)
- 22. Nutrient Absorption Defectsmay be preceded by problems in digestion May be complicated by structural GI changes Changes in transit time Changes in absorptive surfaces Pernicious anemia Post-surgical states (e.g. colectomy, bariatric surgery, short bowel syndrome) Drug effects
- 23. 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
- 24. Drug-Nutrient Interaction DrugReduced 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
- 25. Overall Nutrient Metabolism Related to my physiologic changes Kidneys Liver Changes in body fat and water percentages Chronic disease necessitating dietary modification Altered nutrient utilization as a result of disease states
- 26. Dietary Modifications inChronic 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
- 27. Management • comprehensivegeriatric management • an interdisciplinary approach • multimodality interventions
- 28.
- 29. • Detailed History • Physical and Neurological Examination • Cognitive Evaluation • Behavioral/Emotional Evaluation • Functional Evaluation • Environmental Evaluation • Social Evaluation
- 30. • Physical manifestationsof 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
- 31. 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?
- 32. 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
- 33. Multimodality Interventions •Medical interventions • Drug reviews and monitoring • Nutritional Management • Physical, Occupational, Swallowing and Speech Therapy • Artificial Enteral Feeding • Parenteral Feeding???
- 34. Nutritional Management •Dietary Prescription – Tolerance – Adequacy of prescription and response • Use of nutritional supplements – Tolerance – Cost vs. benefit
- 35. Therapy • Individualizedapproach • Challenges – Assessment – Intervention application – Response and limitations
- 36. Artificial Enteral Feeding • Nasogastric feeding • Gastrostomy (PEG or surgical) • Enterostomy
- 37. Summary • Nutritionaldisorders 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