The evaluation and management of weight loss in the nursing

home patient

Elizabeth A O’Keefe BM BCh,Elizabeth A O’Keefe BM BCh,

Associate Professor of Medicine,Associate Professor of Medicine,

Division of Geriatrics,Division of Geriatrics,

University of PittsburghUniversity of Pittsburgh

Objectives

Develop a rational approach to evaluation Develop a rational approach to evaluation of weight loss in the nursing homeof weight loss in the nursing home

Discuss the role of tube feeding in nursing Discuss the role of tube feeding in nursing home patientshome patients

Review the evidence for other management Review the evidence for other management strategiesstrategies

Prevalence of malnutrition in LTC

Protein energy under-nutrition 17% to 65%Protein energy under-nutrition 17% to 65% Morley 1995Morley 1995

Undernourishment in 50% - 85% of USA care home Undernourishment in 50% - 85% of USA care home residents residents Neel 2001, Crogan 2001Neel 2001, Crogan 2001

In an academic VA nursing homeIn an academic VA nursing home- 43% lost weight in first month - 43% lost weight in first month - 70% lost >10# at some point- 70% lost >10# at some pointSilver 1988Silver 1988

Effects of Malnutrition

Increased mortalityIncreased mortality Increased chance of hospital admissionIncreased chance of hospital admission Prolonged hospital stayProlonged hospital stay FrailtyFrailty Functional impairmentFunctional impairment Pressure ulcersPressure ulcers Increased risk of fracturesIncreased risk of fractures

Effects of Malnutrition

Cognitive impairmentCognitive impairment Decreased QOLDecreased QOL Immune deficiencyImmune deficiency AnemiaAnemia LethargyLethargy DepressionDepression EdemaEdema

Under-nutrition and risk of mortality in elderly patients after hospital discharge

Liu etal. J Gerontol 2002

Weight loss and mortality in LTC

4.6 times more likely to die within the year4.6 times more likely to die within the year

Ryan et al. Nursing 1995Ryan et al. Nursing 1995

4.4 times as likely to die in 9 months4.4 times as likely to die in 9 months Keller et al. J Am Geriatr Soc 2003Keller et al. J Am Geriatr Soc 2003

Odds ratio of 14.7 for death in 6 months Odds ratio of 14.7 for death in 6 months with 10% weight loss over 6 monthswith 10% weight loss over 6 months

Murden et al. J Gen Intern Med 1994Murden et al. J Gen Intern Med 1994

Triggers for nutritional evaluation

Involuntary weight loss of >5% in 30 days Involuntary weight loss of >5% in 30 days or >10% in 180 daysor >10% in 180 days

Leaving >25% of meals in last 7 days or at Leaving >25% of meals in last 7 days or at two-thirds of mealstwo-thirds of meals

A BMI of 19 or lessA BMI of 19 or less Remember that not all weight loss is tissue Remember that not all weight loss is tissue

lossloss

Evaluation of weight loss

Medical and psychiatric illnessesMedical and psychiatric illnesses Individual factorsIndividual factors Institutional factorsInstitutional factors MedicationsMedications

Medical and psychiatric illness

DementiaDementia CHFCHF COPDCOPD ESRDESRD CancerCancer

DiabetesDiabetes Chronic infectionChronic infection ConstipationConstipation DysphagiaDysphagia DepressionDepression

Individual factors

Poor visionPoor vision Poor dentitionPoor dentition Sensory loss (taste and smell)Sensory loss (taste and smell) Poor posturePoor posture Poor manual dexterityPoor manual dexterity Dependence on othersDependence on others Social factors including abuseSocial factors including abuse

Institutional factors

Unappetizing dietUnappetizing diet Failure to help eatingFailure to help eating Inadequate staffInadequate staff Inadequate staff training Inadequate staff training Poor dining environmentPoor dining environment Leaving resident in bed all dayLeaving resident in bed all day Failure to detect and treat weight lossFailure to detect and treat weight loss

Medications associated with weight loss in elderly

AmiodaroneAmiodarone ACEIsACEIs DigoxinDigoxin DiureticsDiuretics MetforminMetformin Anti-epilepticsAnti-epileptics

NarcoticsNarcotics PotassiumPotassium SSRIsSSRIs TheophyllineTheophylline Anticholinesterase Anticholinesterase

inhibitorsinhibitors IronIron

Assessment of weight loss

Serial weightsSerial weights Food percentagesFood percentages Albumin/pre-albuminAlbumin/pre-albumin HemoglobinHemoglobin Fluid statusFluid status Anthropometric measures and BMI not Anthropometric measures and BMI not

usefuluseful

Position of the American Dietetic Association

““Liberalization of the diet prescription can Liberalization of the diet prescription can enhance both QOL and nutritional status in enhance both QOL and nutritional status in older adults in long-term care”older adults in long-term care”

Enhancing food intake

Eating environmentEating environment Positioning at mealtimesPositioning at mealtimes Liquid supplementsLiquid supplements Between meal snacksBetween meal snacks Adding nutrients to foodsAdding nutrients to foods Flavor enhancersFlavor enhancers Favorite foodsFavorite foods

Micronutrient deficiencies

Typical accredited institutional menu cycle Typical accredited institutional menu cycle (2000kcal/day) does not provide adequate (2000kcal/day) does not provide adequate levels of vitamins and minerals to enable levels of vitamins and minerals to enable older adults to meet RDAsolder adults to meet RDAs

Deficient in Vitamin E, pantothenic acid, Deficient in Vitamin E, pantothenic acid, calcium, zinc, copper and manganesecalcium, zinc, copper and manganese

LTC residents typically consume <1500kcalLTC residents typically consume <1500kcal Higher RDAs for older adultsHigher RDAs for older adults

Wendland et al. JAGS 2003

Prevention of weight loss in dementia residents

Interventional and control sitesInterventional and control sites 9-month baseline, 9-month intervention and 9-month baseline, 9-month intervention and

12-month post-intervention periods12-month post-intervention periods Intervention was increased dietitian Intervention was increased dietitian

monitoring and enhanced menusmonitoring and enhanced menus

Keller et al. JAGS 2003

Prevention of weight loss in dementia residents

InterventionIntervention ControlControl

Weight gain >5%Weight gain >5% 27.3%27.3% 6.8%6.8%

Weight loss >5%Weight loss >5% 6.1%6.1% 36.4%36.4%

Average weight Average weight change (%)change (%)

4.8%4.8% -4.5%-4.5%

Dietitian timeDietitian time 533 minutes533 minutes 18 minutes18 minutes

Keller et al. JAGS 2003

“Family-style” mealtimes

Cluster randomized trial in 5 Dutch nursing Cluster randomized trial in 5 Dutch nursing homeshomes

178 non-demented residents178 non-demented residents 6 months6 months Intervention units assigned “Family-style” Intervention units assigned “Family-style”

(FS)(FS) Control units continued with pre-plated Control units continued with pre-plated

meals (C)meals (C)Kristel et al. BMJ 2006

Outcomes

Change Change (FS)(FS)

Change Change (C)(C)

Difference in Difference in change (CI)*change (CI)*

QOL (0-100)QOL (0-100) 0.40.4 -5.0-5.0 6.1 (2.1to 10.3)6.1 (2.1to 10.3)

Fine motor Fine motor functionfunction

-0.5-0.5 -2.1-2.1 1.8 (0.6 to 3.0)1.8 (0.6 to 3.0)

Body weight (kg)Body weight (kg) 0.50.5 -1.1-1.1 1.5 (0.6 to 2.4)1.5 (0.6 to 2.4)

Energy (kJ)Energy (kJ) 481481 -420-420 991 (504 to 1479)991 (504 to 1479)

*Adjusted for age, LOS, sex, nursing home and cluster effect of units

Oral supplements in LTC

Stabilization of weight loss/slow regain over 9 Stabilization of weight loss/slow regain over 9 months months Johnson et al. J Am Geriatr Soc 1993Johnson et al. J Am Geriatr Soc 1993

In France, malnourished patients gained about 1.5 In France, malnourished patients gained about 1.5 kg over 60days kg over 60days Lauque et al. Age Ageing 2000Lauque et al. Age Ageing 2000

Randomized double-blind placebo study in Randomized double-blind placebo study in demented patients with supplement between meals: demented patients with supplement between meals: OS gained 1.4OS gained 1.4±2.4kg: Control lost 0.8±3.0kg ±2.4kg: Control lost 0.8±3.0kg Wouters-Wesseling et al. Eur J Clin Nutr 2002Wouters-Wesseling et al. Eur J Clin Nutr 2002

Oral supplements (OS) in LTC

Not given as often as prescribedNot given as often as prescribed Staff spend minimal time assisting residents Staff spend minimal time assisting residents

consuming them consuming them Minimal calories received from OSMinimal calories received from OS

- average 144 calories/day (between meals)- average 144 calories/day (between meals)

- average 230 calories/day (with meals)- average 230 calories/day (with meals)Kayser-Jones. JAGS 2006

Oral supplements (OS) in LTC

Often associated with significant reductions Often associated with significant reductions in “total energy, protein , fat, water, fiber, in “total energy, protein , fat, water, fiber, and many vitamins and minerals, in the and many vitamins and minerals, in the habitual diethabitual diet

Reduction in appetite (if given with, or Reduction in appetite (if given with, or between, meals)between, meals)

3 European studies showed weight gain and 3 European studies showed weight gain and improvement in nutritional statusimprovement in nutritional status

Oral supplements (OS) in LTC

Supplements should not be used as a Supplements should not be used as a substitute for food and nursing caresubstitute for food and nursing care

The role of appetite stimulants in nursing home residents with weight loss

Megestrol acetate 69 VA NH patients with wt loss >5%, or 20% 69 VA NH patients with wt loss >5%, or 20%

below ideal body weightbelow ideal body weight Randomized, double-blind, Megestrol 800mg/day Randomized, double-blind, Megestrol 800mg/day

vs placebo for 12 weeksvs placebo for 12 weeks At 12 weeks, appetite, well-being and enjoyment At 12 weeks, appetite, well-being and enjoyment

of life improved but no wt gainof life improved but no wt gain At week 20, significant wt gain in treatment group At week 20, significant wt gain in treatment group

of 2.45kg vs. -0,4kg in placeboof 2.45kg vs. -0,4kg in placebo Megestrol failed to increase weight in a frail Megestrol failed to increase weight in a frail

subset subset

Yeh. JAGS 2000

Concerns about use in LTC

Frail patients least likely to respondFrail patients least likely to respond More useful with high cytokine levelsMore useful with high cytokine levels Need to make sure patients have access to Need to make sure patients have access to

food/adequate feedingfood/adequate feeding Side effects include fluid retention and--Side effects include fluid retention and-- Thromboembolism with rates of DVT in Thromboembolism with rates of DVT in

NH patients reported from 4.9% to 32%NH patients reported from 4.9% to 32%

Dronabinol

Synthetic tetrahydrocannabinolSynthetic tetrahydrocannabinol Reduces nausea, improves appetite and weight Reduces nausea, improves appetite and weight

gain in AIDSgain in AIDS Placebo-controlled, crossover study in 15 Placebo-controlled, crossover study in 15

Alzheimer’s patients - more weight gain in Rx Alzheimer’s patients - more weight gain in Rx group, possibly due to decrease in disturbed group, possibly due to decrease in disturbed behaviorbehavior

Side effects include delirium, somnolence, ataxiaSide effects include delirium, somnolence, ataxia ExpensiveExpensive

Volicer. Int J Geriatr Psychiatry 1997

Mirtazapine

NA and 5-HT propertiesNA and 5-HT properties Low dose (15mg) is associated with Low dose (15mg) is associated with

increased appetite, weight gain and increased appetite, weight gain and improved sleep (potent Himproved sleep (potent H11 antagonist) antagonist)

Safety in non-depressed elderly unknownSafety in non-depressed elderly unknown

Retrospective chart review in depressed NH patients

Goldberg. JAGS 2002

Randomized, double-blind comparative studies In an 8-week study (n=246) comparing wt In an 8-week study (n=246) comparing wt

gain on mirtazapine and paroxetine: 11% gain on mirtazapine and paroxetine: 11% gained wt (mean 1.7kg) on mirtazapine vs. gained wt (mean 1.7kg) on mirtazapine vs. none on paroxetinenone on paroxetine

In a 6-week study (n=150) comparing wt In a 6-week study (n=150) comparing wt gain on mirtazapine, trazodone and placebo, gain on mirtazapine, trazodone and placebo, wt gain (mean 1.3kg) seen with mirtazapine wt gain (mean 1.3kg) seen with mirtazapine onlyonly

Schatzberg. Am J Psychiatry 2002Halikas. Hum Psychopharmacol. 1995

Antipsychotics

No significant weight changes seen in a trial No significant weight changes seen in a trial comparing varying doses of olanzapine vs. comparing varying doses of olanzapine vs. placebo to manage behavior in patients with placebo to manage behavior in patients with Alzheimer’sAlzheimer’s

Street. Arch Gen Psychiatry 2000

Tube feeding in advanced dementia

““To PEG or not to PEG that is the To PEG or not to PEG that is the question?”question?”

Demographics of PEG

PEG placement in Medicare beneficiaries PEG placement in Medicare beneficiaries was increasing:was increasing:

- 81,105 in 1991- 81,105 in 1991

- 121,000 in 1995- 121,000 in 1995 34% of nursing home residents with 34% of nursing home residents with

advanced cognitive impairment in 1999 had advanced cognitive impairment in 1999 had PEGPEG

Nursing home resident characteristics associated with PEG

Age: Age: 90 years +90 years + 1.001.0065-69years65-69years 1.32 (1.27-1.38)1.32 (1.27-1.38)

MenMen 1.15 (1.14-1.18)1.15 (1.14-1.18) Race: Race: WhiteWhite 1.001.00

BlackBlack 1.55 (1.51-1.58)1.55 (1.51-1.58) Absent:Absent: DNRDNR 1.07 (1.06-1.10)1.07 (1.06-1.10)

Living willLiving will 1.32 (1.28-1.35)1.32 (1.28-1.35)Alzheimer’s Alzheimer’s 1.37 (1.34-1.40)1.37 (1.34-1.40)

Present: Present: CVACVA 1.84 (1.82-1.86)1.84 (1.82-1.86)

Mitchell. JAMA 2003

Facility characteristics associated with PEG

Urban locationUrban location 1.14 (1.11-1.16)1.14 (1.11-1.16) For profit For profit 1.09 (1.06-1.12)1.09 (1.06-1.12) >80% Medicaid beds>80% Medicaid beds 1.00 (0.97-1.03)1.00 (0.97-1.03) Residents with DNR:Residents with DNR:

>80%>80% 1.001.00

<10%<10% 1.67 (1.54-1.80)1.67 (1.54-1.80) No dementia unitNo dementia unit 1.11 (1.07-1.15)1.11 (1.07-1.15) No NP or PA on staffNo NP or PA on staff 1.07 (1.04-1.10)1.07 (1.04-1.10)

Mitchell. JAMA 2003

State Variation in Feeding Tube Use

Teno. JAMA 2002

Medicare costs for PEG

PEG placement ($2,200)PEG placement ($2,200) ER visits and hospital admissions for tube- related ER visits and hospital admissions for tube- related

complications ($2,449 in first year)complications ($2,449 in first year) Skilled nursing benefits for 100 daysSkilled nursing benefits for 100 days Overall care plan may be more aggressive Overall care plan may be more aggressive From the Medicare perspective tube feeding in From the Medicare perspective tube feeding in

advanced dementia is associated with high costs advanced dementia is associated with high costs and no demonstrable health benefitsand no demonstrable health benefits

Mitchell. JAGS 2003

Medicaid costs for PEG

PEG decreases nursing time for feeding and PEG decreases nursing time for feeding and giving meds (15-30 minutes/day vs 45-90) giving meds (15-30 minutes/day vs 45-90)

Additional cost of enteral feed/day is $3.15Additional cost of enteral feed/day is $3.15 Reimbursement for totally dependent patients with Reimbursement for totally dependent patients with

PEG is $190/day vs $151 no PEGPEG is $190/day vs $151 no PEG From the Medicaid perspective there is a potential From the Medicaid perspective there is a potential

fiscal incentive to tube feed persons with fiscal incentive to tube feed persons with advanced dementiaadvanced dementia

Mitchell. JAGS 2003

Unaware of hunger or fail to respond to itUnaware of hunger or fail to respond to it Refuse to open mouth or spit food outRefuse to open mouth or spit food out Chew repetitively and hold food in mouthChew repetitively and hold food in mouth Fail to initiate the swallowing reflexFail to initiate the swallowing reflex Swallow ineffectively and aspirateSwallow ineffectively and aspirate Net result is weight loss, dehydration and Net result is weight loss, dehydration and

inability to give medicationinability to give medication

Eating problems in dementia

What do we hope to achieve?

To prolong lifeTo prolong life To prevent malnutritionTo prevent malnutrition To prevent aspirationTo prevent aspiration To improve functional statusTo improve functional status To heal pressure ulcersTo heal pressure ulcers To make the patient more comfortableTo make the patient more comfortable Hospital dischargeHospital discharge

Mortality data in elderly after PEG placement

30 day 1 year

Nursing home population (n=46) 20% 63%

Medicare (n=81,105) 24%

Quebec elderly (n=175) 18% 54%

Community (n=97) 22% (65% at 18 months)

Mortality in patients hospitalized with advanced dementia

Meier. Arch Int Med 2001

PEG-related complications

Mortality, major and minor complication rate of Mortality, major and minor complication rate of procedure 1%, 3% and 13%procedure 1%, 3% and 13%

Subsequent complication rate 34% - 70%Subsequent complication rate 34% - 70% Tube leaks, blockage and local infection Tube leaks, blockage and local infection Tube migrationTube migration Aspiration pneumonia in up to 30%Aspiration pneumonia in up to 30% Gastric distensionGastric distension Diarrhea Diarrhea HyperglycemiaHyperglycemia

Negative aspects of PEG placement

Denial of pleasure from eatingDenial of pleasure from eating Social isolationSocial isolation Increased use of restraintsIncreased use of restraints Increased stool and urine productionIncreased stool and urine production Prolonging life without qualityProlonging life without quality May necessitate nursing home admissionMay necessitate nursing home admission

Nutritional Interventions in the Treatment of Pressure Ulcers

Author Setting Intervention OutcomeBreslow Long-term

care24% protein vs 14% protein enteral feeding

Greater healing with higher protein

Chernoff Long-term care

25% protein vs 17% protein enteral feeding

Greater healing with higher protein

ter Riet Long-term care

Vitamin C 50 mg vs 1000 mg No difference in healing

Norris Long-term care

Zinc sulfate 200 mg TID No difference in healing

Henderson Long-term care

Enteral feeding No difference in prevalence at 3 mo

Mitchell Long-term care

Enteral feeding No difference in prevalence after 2 y

Tube feeding in patients with advanced dementia

““The widespread practice of tube feeding The widespread practice of tube feeding should be carefully reconsidered, and we should be carefully reconsidered, and we believe that for severely demented believe that for severely demented patients the practice should be patients the practice should be discouraged on clinical grounds”discouraged on clinical grounds”

Finucaine TE et al. JAMA 1999Finucaine TE et al. JAMA 1999

Rethinking the role of tube feeding in patients with advanced dementia

“ “ There is a pervasive failure - by both There is a pervasive failure - by both physicians and the public - to view physicians and the public - to view advanced dementia as a terminal illness, advanced dementia as a terminal illness, and there is a strong conviction that and there is a strong conviction that technology can be used to delay death”technology can be used to delay death”

Gillick MR. N Engl J Med 2000Gillick MR. N Engl J Med 2000

Decision-maker expectations

Visual analog ratingsConditionCondition Initial Initial

(survivors)(survivors)Initial Initial (deceased)(deceased)

3 month 3 month (survivors)(survivors)

NutritionNutrition 9.29.2 6.36.3 2.8*2.8*

DiscomfortDiscomfort 5.75.7 3.53.5 3.7*3.7*

QOLQOL 6.36.3 7.37.3 4.34.3

Difficulty Difficulty feedingfeeding

7.07.0 7.77.7 3.03.0

SatisfactionSatisfaction N/AN/A N/AN/A 1.71.7

Where 1 is the best outcome and 10, the worst. * = p<0.05

Thoughts……

PEG placement in advanced dementia appears to PEG placement in advanced dementia appears to benefit the family more than the patientbenefit the family more than the patient

Is it ethically justifiable to submit someone to an Is it ethically justifiable to submit someone to an invasive procedure of no proven benefit to relieve invasive procedure of no proven benefit to relieve the suffering of their family?the suffering of their family?

Is this a justifiable use of healthcare resources?Is this a justifiable use of healthcare resources? How can we improve counseling about PEG How can we improve counseling about PEG

placement to address this issue?placement to address this issue?

An approach to counseling about PEG tube decisions

Do #1

Meet with the family to discuss the overall Meet with the family to discuss the overall prognosis and define expectationsprognosis and define expectations

Do #2

Review advance directivesReview advance directives

Do #3

Discuss likely outcomes after PEG Discuss likely outcomes after PEG

Do #4

Review possible complications and Review possible complications and negative factors of long-term feeding, not negative factors of long-term feeding, not just of the procedure itselfjust of the procedure itself

Do #5

Discuss concerns about thirst and hungerDiscuss concerns about thirst and hunger

Do #6

Respect cultural and religious differencesRespect cultural and religious differences

Do #7

Discuss alternatives to PEG feedingDiscuss alternatives to PEG feeding

Don’t #1

Leave the discussion too lateLeave the discussion too late

Don’t #2

Suggest a “trial” of PEG feedingSuggest a “trial” of PEG feeding

Don’t #3

Order a PEG in someone with impaired Order a PEG in someone with impaired gastric emptyinggastric emptying

Don’t #4

Try and impose your values on patients or Try and impose your values on patients or familiesfamilies

Decision tree for PEG

Skelly: Curr Opin Clin Nutr Metab Care2002

Management of weight loss

Multidisciplinary approachMultidisciplinary approach Counsel patients and familiesCounsel patients and families Address dietary preferences, texture, oral Address dietary preferences, texture, oral

factors, social issuesfactors, social issues Address swallowing dysfunctionAddress swallowing dysfunction Make sure someone is feeding the residentMake sure someone is feeding the resident

Management of weight loss

Control medical illnessControl medical illness Treat depression Treat depression Reduce medications!!!!Reduce medications!!!! Dietary supplementsDietary supplements Rarely consider appetite stimulantsRarely consider appetite stimulants Tube feeding not a viable option in most Tube feeding not a viable option in most

casescases

Conclusions

Weight loss in the NH is complexWeight loss in the NH is complex Important to identify residents at high riskImportant to identify residents at high risk Documentation is criticalDocumentation is critical Accept that weight loss often occurs at the Accept that weight loss often occurs at the

end-of lifeend-of life May be more important to focus on QOLMay be more important to focus on QOL