Tag: Dronabinol

 

Aging is characterized by diminished organ system reserves, weakened homeostatic controls, and increased heterogeneity among individuals, influenced by genetic and environmental factors.

Nutritional needs of the older individual are determined by multiple factors, including specific health problems and related organ system compromise; a human level of activity, energy expenditure, and caloric requirements; the flexibility to access, prepare, ingest, and digest food; and private food preferences.

This topic will discuss assessment of nutrition within the older adult, still because the etiology, evaluation, and treatment of weight loss, overnutrition, and specific common nutrient deficiencies. Related problems with geriatric health maintenance and nutritional assessment are discussed separately.

SCREENING FOR NUTRITIONAL STATUS
Data from studies of acute hospitalization in older patients suggest that up to 71 percent are at nutritional risk or are malnourished.
Malnutrition is related to increased mortality risk. the subsequent criteria for the diagnosis of malnutrition are recommended in an exceedingly consensus statement from the Academy of Nutrition and Dietetics (Academy) and also the American Society for Parenteral and Enteral Nutrition (ASPEN):
Two or more of the subsequent six characteristics:
• Insufficient energy intake
• Weight loss
• Loss of muscle mass
• Loss of subcutaneous fat
• Localized or generalized fluid accumulation which will mask weight loss
• Diminished functional status as measured by handgrip strength.

Weight

Serial measurements of weight offer the best screen for nutritional adequacy and alter in nutritional status in older adults.

Obtaining periodic body weights could also be challenging, particularly in frail patients. A chair or bed scale that’s regularly calibrated could also be needed for patients who cannot stand on an upright exerciser scale. Low weight is defined as <80 percent of the recommended weight .

Weight loss
Studies suggest that weight loss in older adults, especially if it’s not volitional, is predictive of mortality. Loss of as little as 5 percent of weight over a 3 year period is related to increased mortality among community-dwelling older adults .

Weight loss for those with a BMI below 30 likely poses a greater mortality threat to older adults than not losing weight or of getting a BMI of 25 to 30.

However, obesity (BMI ≥30) continues to own a negative impact on morbidity and mortality in older adults. The relative good thing about intentional weight loss in obese older adults with osteoarthritis, impaired activity tolerance, DM, and coronary heart condition, especially when combined with exercise, is becoming increasingly apparent .

Weight loss is taken into account to be clinically significant with the subsequent parameters
• ≥2 percent decrease of baseline weight in one month
• ≥5 percent decrease in three months, or
• ≥10 percent in six months
In the long run care setting, a clinically significant weight loss episode is defined by the long run care Minimum Data Set (MDS) as loss of 5 percent of usual weight in 30 days, or 10 percent in 6 months.

Screening tools
variety of screening tools are developed for identifying older adults in danger for poor nutrition.

• The Nutritional Risk Screening (NRS) 2002 has two components: a screening assessment for undernutrition and an estimate for disease severity. Undernutrition is estimated with three variables: BMI, percent recent weight loss, and alter in food intake . Disease severity ranges from a score of zero (for those with chronic illnesses or a hip fracture) to a few (for those within the ICU with an APACHE score of 10). In hospitalized patients, the NRS 2002 showed a sensitivity of 39 to 70 percent and a specificity of 83 to 93 percent when put next to the Mini Nutritional Assessment and therefore the Subjective Global Assessment .
• The Simplified Nutrition Assessment Questionnaire (SNAQ), a four item screener, was tested in community-dwelling older adults and long-term care residents . In those populations, it had a sensitivity and specificity of 88.2 and 83.5 percent, respectively, for identification of older persons in danger for five and 10 percent weight loss, respectively ( figure 1 ).
• SCREEN II (Seniors within the Community: Risk Evaluation for Eating and Nutrition) may be a 17-item tool that assesses nutritional risk by evaluating food intake, physiological barriers to eating (difficulty with chewing or swallowing), weight change, and social/functional barriers to eating. The tool has excellent sensitivity and specificity, yet as interrater and test/retest reliability .An eight-question abbreviated version of SCREEN II is additionally available .
• The Malnutrition Universal Screening Tool (MUST) incorporates BMI, weight loss in three to 6 months, and anorexia for five days thanks to disease. it’s commonly utilized in the uk and is especially sensitive for recognition of protein energy undernutrition in hospitalized patients .
• The Malnutrition Screening Tool (MST) was developed to be used in acutely hospitalized patients and also validated to be used in cancer patients (average age 57 to 60 years, range 15 to 89) . It asks two simple questions: “Have you been eating poorly due to a decreased appetite?” and “Have you lost weight recently without trying?” The sensitivity of the MST in hospitalized patients ranges from 74 to 100% with a specificity of 76 to 93 percent compared to the Subjective Global Assessment.
• The Mini Nutritional Assessment (MNA) consists of a world assessment and subjective perception of health, moreover as questions specific to diet, and a series of anthropomorphic measurements ( figure 2 ) .It has been widely validated and is predictive of poor outcomes .The Mini Nutritional Assessment-Short Form uses six questions from the total MNA and may substitute calf circumference if BMI isn’t available. A validation study demonstrated good sensitivity compared to the total MNA.
The two screening tools within the highest quartile for sensitivity (>83 percent) and specificity (>90 percent) were the MNA (SF) and therefore the MST.

UNDERNUTRITION SYNDROMES
The prevalence of malnutrition in older adults relies upon the population studied, varying by geography, age distribution, and living situation. A review of results of the Mini Nutritional Assessment across settings and countries in Europe, the u. s. and African nation, found the prevalence of malnutrition among 4507 people (mean age 82.3, 75.2 percent female) was 22.8 percent Highest rates were within the rehabilitation setting (50.5 percent) and lowest among community dwellers (5.8 percent).
Over a 3rd of hospitalized older adults (38.7 percent) during this study met the standards for malnutrition.
Compared to younger adults, undernutrition in older individuals is both more common and should have greater impact on outcomes, including physical function healthcare utilization, and length of stay for surgical hospitalizations
Inadequate energy intake is common in hospitalized older adults, with increased risk related to poor appetite, higher BMI, diagnosis of infection or cancer, delirium, and want for assistance with feeding .Some studies suggest that older adults are less ready to adapt to underfeeding.
One study found that, following a period of experimental underfeeding, older adults experienced less frequent hunger than younger adults, and didn’t regain the whole amount of weight they’d lost when allowed to consume food freely for 6 months while on the average younger adults regained all their lost weight.
In contrast, the same study didn’t demonstrate age differences in ad lib intake, anthropometric indices, gastric emptying rate, and cholecystokinin levels in blood after a period of underfeeding and so consumption of food freely
The lack of ability to catch up on periods of low food intake because of illness or other difficulties may end up in long-term, persistent weight changes, especially when combined with social, medical, or psychological factors which will negatively impact weight.
Involuntary weight loss is driven by:
• Inadequate dietary intake
• Appetite loss (anorexia)
• Disuse or muscle atrophy (sarcopenia)
• Inflammatory effects of disease (cachexia)
or a mixture of those factors.
Inadequate dietary intake
There are multiple causes of weight loss because of inadequate nutrient intake.
These include social (eg, poverty, isolation), psychological (eg, depression, dementia), medical (eg, edentulism, dysphagia), and pharmacological issues.

Social factors
Social factors contributing to weight loss include:
• Increased likelihood of isolation at mealtimes. One third of persons over 65, and half over 85 live alone, which usually decreases food enjoyment and calorie intake. Several studies have demonstrated that older adults who eat the presence of others consume quite those that eat alone.

• Financial limitations affecting food acquisition. A greater proportion of older adults live near the personal income, compared to the overall population. Individuals with fixed incomes may use money previously spent on food for medications and other needed items.

Medical and psychiatric factors
The most important medical and psychiatric causes of weight loss in older adults are malignancy and depression.
• Malignancy was identified because the cause for weight loss in 9 percent of older patients during a study of medical outpatients, and was second to depression because the most frequent identifiable reason for undernutrition .
• In another study of unexplained weight loss in 45 ambulatory older adults, the foremost common identified cause for weight loss was depression (18 percent), again followed by malignancy (16 percent).

• a 3rd report found cancer, predominantly of the digestive tube, as a reason for weight loss in 36 percent of the 154 patients evaluated .

• Depression and dysphoria are common in older adults and infrequently remain unrecognized and undertreated. Depression is a very important reason behind weight loss within the subacute care and home settings, furthermore as in older patients within the community.

• during a chart review of 1017 medical outpatients, as an example, depression was the explanation for weight loss in 30 percent of the older patients, compared to only 15 percent in younger patients .

• Dysphagia is present in approximately 7 to 10 percent of the older adult population and encompasses a negative effect on energy intake .

• Dysphagia occurs in about one half patients with acute first-ever stroke or with Parkinson disease .

• Oropharyngeal dysphagia may occur thanks to stroke, Parkinson disease, amyotrophic lateral sclerosis, Zenker’s diverticula, and other motility or structural disorders. Esophageal dysphagia are often thanks to motility problems (eg, achalasia, diffuse esophageal spasm, scleroderma) and structural issues.

Other important medical etiologies to contemplate include:
• Endocrine disorders (hyperthyroidism, new onset diabetes mellitus)
• End organ disease (congestive heart disease, end stage renal disease, chronic obstructive pulmonary disease, hepatic failure)
• Gastrointestinal disorders (celiac disease, ischemic bowel, inflammatory bowel disease, pancreatic insufficiency, ulceration disease, GERD)
Infections (tuberculosis)
• Rheumatologic disorders (polymyalgia rheumatica, arthritis)
• Neurological conditions (Parkinson disease, chronic pain)
• Alzheimer’s disease (especially among those with behavioral and psychological symptoms)
• Drug or alcohol dependence
• Medication side effects ( digoxin , opioids, serotonin-reuptake inhibitors, diuretics, and topiramate )
Additionally, medical or dental conditions in older adults may impair the flexibility to eat.
Paralysis from stroke, severe arthritis, hand tremors, and dementia may result in routine need for feeding assistance from others.

Chewing difficulty puts older adults in danger for poor intake. in a very study of non-institutionalized older adults, edentulousness doubled the chance for significant weight loss over a one-year period, after adjusting for gender, income, age, and baseline weight .

Physiologic factors
Physiologic factors related to weight loss include age-related decrease in taste and smell sensitivity, delayed gastric emptying, early satiety, and impairment within the regulation of food intake.
• Age raises the brink for odor detection and lowers perceived odor intensity .
• The number of taste buds remains constant, but thresholds for recognition of salt and other specific tastes increase.
• Impaired taste and smell likely alter the cephalic phase of digestion, affecting learned associations between the taste and smell of food with signals involved in meal initiation, volume of food intake, and meal termination.

• Decrease within the rate of gastric emptying in older adults may lead to prolonged antral distension with reduced hunger and increased satiety .

• Aging may influence production of, and/or CNS sensitivity to, several digestive hormones thought to be involved in satiety.

• Glucagon, glucagon-like peptide-1 (GLP-1), cholecystokinin (CCK), leptin, and ghrelin are peripheral satiety signals and appear to be less well detected by the brain with increased age .

• Causes of impaired regulation of food intake include decreased stimulatory effects of neurotransmitters involved in appetite (eg, opioids, neuropeptide Y, the orexins and ghrelin) and increased sensitivity to the inhibitory effects of corticotropin-releasing factor, serotonin, and cholecystokinin.

Anorexia
Anorexia, the decrease in appetite, in older adults is influenced by multiple physiological changes.
Food intake gradually diminishes with age .
Much of the intake reduction in early adulthood is an appropriate response to decreased energy needs because of reduced physical activity, decreased resting energy expenditure (REE), and/or loss of lean body mass.

Changes in taste and smell result in a decreased desire to eat and early satiety develops with age, associated with gastrointestinal changes and gastric hormone changes, as discussed above.

Appetite regulation is further tormented by illness, drugs, dementia, and mood disorders. In 292 older adults from assisted living facilities or senior centers, fair to poor emotional well-being was most closely related to poor appetite (OR 5.60, 95% CI 2.60-12.07) .

Cachexia
Cachexia has been defined as a “complex metabolic syndrome related to underlying illness, and characterized by loss of muscle with or without loss of fat mass” .
It is related to increased morbidity.
Anorexia, inflammation, insulin resistance, and increased muscle protein breakdown are frequently related to cachexia.

Cachexia is distinct from starvation, age-related loss of muscle mass, or psychiatric, intestinal, or endocrinologic causes of weight loss.
Cachexia involves many dysregulated pathways, resulting in an imbalance between catabolism and anabolism.
Because of the presence of underlying inflammation and catabolism, cachexia often is proof against nutritional intervention.
Cachexia usually occurs within the setting of underlying illness involving a cytokine-mediated response. Such illnesses include cancer, end-stage renal disease, chronic pulmonary disease, congestive cardiopathy, rheumatoid arthritis, and AIDS.

Pro-inflammatory cytokines commonly involved in cachexia include interleukin-1 (IL-1), interleukin-6 (IL-6), and tumor necrosis factor-a (TNF-a) .
These cytokines contribute to lipolysis, muscle protein breakdown, and nitrogen loss, additionally to producing anorexia.
They augment the acute phase response, up-regulate the assembly of CRP and down-regulate the transcription of albumin .

In a study of older Framingham Heart Study participants, levels of insulin-like protein 1 (IGF-1) and muscle mass decreased, whereas interleukin 6 levels increased, with age .
These changes appear to occur even within the absence of overt disease, suggesting that a subclinical inflammatory process is also a part of normal aging.
Although elevated pro-inflammatory cytokines (especially IL-1, IL-6 and TNF-a) are commonly seen in older adults, levels are higher in those with cachexia.

Sarcopenia
Sarcopenia may be a syndrome characterized by the loss of muscle mass, strength, and performance .
Low muscle mass is defined as a decrease in appendicular muscle mass two standard deviations below the mean for young healthy adults , and is sometimes measured by DEXA or bio-electrical impedance in clinical practice.
Unlike cachexia, sarcopenia doesn’t require the presence of an underlying illness.
Also, whereas the majority with cachexia are sarcopenic, most sarcopenic individuals don’t seem to be considered cachectic .
Sarcopenia is related to increased rates of functional impairment, disability, falls and mortality .
The causes of sarcopenia are multifactorial and might include disuse, changing endocrine function, chronic diseases, inflammation, insulin resistance, and nutritional deficiencies .

Sarcopenia was identified in 53 to 57 percent of men, and 43 to 60 percent of ladies, over the age of 80 in one study.
Loss of muscle mass, in the course of decreased muscle strength, can occur in overweight individuals (sarcopenic-obese) additionally as in normal and underweight individuals.

Causes of sarcopenia include endocrine changes, activation of proinflammatory cytokines, reduced alpha motor units within the medulla spinalis, decreased physical activity, and suboptimal protein intake.
• Reductions in testosterone and estrogen that accompany aging appear to accelerate the event of sarcopenia .

• Relative deficiencies of estrogen and testosterone contribute to muscle catabolism and promotion of catabolic cytokines like IL-1 and IL-6 .
Testosterone replacement may increase muscle mass, but studies haven’t demonstrated similar benefit for estrogen replacement.
• Insulin resistance increases with age.
• Insulin inhibits muscle breakdown and therefore the reduction of insulin action on muscle may contribute to muscle catabolism .
• Physical activity declines with age. within the u. s., 28 to 34 percent of adults aged 65 to 74 and 35 to 44 percent of adults ages 75 or older are inactive .
• Inactivity exacerbates ongoing muscle loss and increases proportion of body fat mass .
• Inadequate protein intake may also contribute to sarcopenia. in an exceedingly small randomized study of postmenopausal women, consumption of inadequate dietary protein (0.45 g/kg/d) compared to adequate intake (0.92 g/kg/d) for 6 weeks led to deterioration in strength and lean body mass. In one US survey, over 10 percent of adults over age 60 within the US consumed but this RDA for protein .

A study within the uk of 2983 men and ladies aged 59 to 73 years found an independent correlation between increased grip strength and consumption of fatty fish .
The speculation is raised that the anti-inflammatory properties of omega-3-fatty acids is also an element in prevention of sarcopenia.

EVALUATION OF WEIGHT LOSS
Recommendations vary on the degree of weight loss, and also the period of your time for weight loss, that ought to prompt clinical investigation.
One commonly accepted definition for clinically important weight loss is loss of 4 to five percent of total weight over 6 to 12 months.
Unintentional weight loss should result in clinical concern no matter whether the patient is overweight at baseline. Whether or not intentional weight loss is of concern remains a matter of some speculation.

Initial evaluation
the subsequent steps are suggested within the initial evaluation of an older one who is noted to own lost weight, or for whom concern is raised about weight loss by the patient, relations, or caregivers.
• Document the load loss.
• While it’s important to notice objective evidence of weight loss from recorded serial weights over time, this information is commonly not available.

Body fat and lean muscle mass is also estimated using bioelectrical impedance or anthropometric measures like mean upper arm circumference (MUAC) or mid-arm circumference.
• MUAC measures the circumference of the left upper arm at the mid-point between the tip of the shoulder and also the tip of the elbow (olecranon process and also the acromium).
• MUAC of but 22 cm for girls and 23 cm for men are implicative chronic energy deficiency.
• Although connotative malnutrition, it’s unclear whether MUAC predicts mortality and morbidity. The MUST screening tool and therefore the MNA both use mid-arm circumference measures as a part of their assessment.

Bioelectrical impedance measures are available to be used with wheelchair bound and bedbound patients, although bioelectrical impedance is significantly influenced by hydration status.
• Evaluate appetite and dietary intake.
• Determining if there has been a change in hunger and satiety may provide more clinically revealing information than performing a proper dietary recall.
• Patients should be questioned regarding appetite, their dietary intake in regard to their usual pattern, the amount of meals they consume per day, portion size, snacks between meals, if and once they feel full during their meal, and whether the patient likes what he or she is eating.
• The SGA, MNA, and SNAQ all evaluate aspects of dietary intake during this way.
• A more formal dietary intake assessment are often obtained with a dietetic consult.
• Perform an entire history and physical examination, and order appropriate laboratory studies.
• As a baseline, we propose laboratory evaluation for evidence of metabolic or disease, to incorporate a basic chemistry profile including glucose and electrolytes, TSH, complete blood count (CBC), and CRP if cachexia is suspected.
• Chest and plain abdomen radiographs could also be considered.
• Although studies describing the causes of IVL have routinely performed chest x-rays and abdominal films, there’s no clear evidence of their value. Order addition studies supported suspicion of underlying disease from the patient’s history and examination.
Those with no localizing findings and with normal complete blood count, biochemical profile, or chest and plain abdomen radiographs are considered by some to possess isolated involuntary weight loss (IIVL).
In one series, a bit quite one-third of patients with IIVL were ultimately diagnosed with a malignancy.
statistical method found the strongest predictors of neoplasm within the setting of IIVL were age >80 years, white blood corpuscle count >12,000/mm3, albumen <3.5 g/dL, serum alkaline phosphatase > 300 UI/L, and serum lactate dehydrogenase (LDH) >500 IU/L.
These authors recommend CBC, ESR, albumin, liver function studies, LDH, and abdominal ultrasound.
Subsequent evaluation
There are not any clear guidelines for the way to proceed within the assessment of a patient with weight loss and negative initial findings.
The diagnostic yield of a thoracic/abdominal/pelvic CT examination to assess for occult or metastatic malignant disease has not been determined.
Incidental findings are common, the studies are costly, and will be inappropriate in patients who are frail or who have multiple comorbidities.
• In the absence of evidence-based recommendations, we advise ordering a thoracic/abdominal/pelvic CT scan with and without contrast for the patient with significant ongoing weight loss.
• An MRI is also ordered as an alternate when IV contrast can’t be administered, assuming there are not any contraindications; patients with chronic renal disorder shouldn’t be gadolinium.
• Upper gastrointestinal endoscopy is indicated for patients with early satiety.
• Colonoscopy isn’t indicated within the evaluation of weight loss, as carcinoma doesn’t usually induce weight loss or cachexia unless there’s obstruction or extensive metastases

TREATMENT OF WEIGHT LOSS

When an underlying explanation for weight loss is identified, like depression, a medical illness, or inability to chew food, it’s obviously important to treat the condition.
additionally, nutritional repletion should be provided to revive the patient to a target weight, with recognition that weight correction within the older population is a smaller amount readily accomplished than in younger people.
The Council for Nutritional Clinical Strategies in Long-Term Care has developed an evidence-based approach to nutritional surveillance and management for patients in long run care .
Treatment recommendations are supported common reversible causes of malnutrition, as described by the acronym “MEALS ON WHEELS” ( table 2 ). Likewise, the American Academy of Home Care Physicians has developed guidelines for unintended weight loss in home care patients .
Data from studies of acute hospitalization in older patients suggest that up to 71 percent are at nutritional risk or are malnourished .
One randomized trial found that individualized nutritional management by a dietician (involving one visit during hospitalization and three home visits following discharge) resulted in improved scores on the Mini Nutritional Assessment and better albumin levels within the intervention group, compared to manages .
Decreased mortality rates at six months were also found (3.8 versus 11.6 percent for intervention and controls respectively), although high study dropout rates and issues with randomization allocation may have impacted this finding.
Calorie and protein requirements
Calorie needs (the estimated energy requirement, or EER) are often calculated in older adults using the subsequent equations :
• For women: 354.1 – (6.91 x age [y]) + PAC x (9.36 x weight [kg] + 726 x height [m]).
• For men: 661.8 – (9.53 x age [y]) + PAC x (15.91 x weight [kg] + 539.6 x height [m]).
The Physical Activity Coefficient (PAC) is decided as follows:
• Sedentary PAC = 1.0
• Low activity PAC = 1.12
• Active PAC = 1.27
• Very active PAC = 1.45
Protein needs don’t appear to alter significantly with age, although studies evaluating protein intake in older adults have shown wide variation in optimal protein requirements.
A meta-analysis of information from 19 studies of balance in older adults found no significant effect old on the number of protein required per kilogram of weight .
The Institute of medication has determined that the recommended dietary allowance (RDA) for protein for men and girls 51 years old and older is 0.80 g/kg body weight/day .

Inadequate food intake

If the patient’s food intake is inadequate:
• Lift dietary restrictions whenever possible. In one study, undernutrition (average weight loss >1 pound per month, albumen <3.5 g/dl) was related to dietary restrictions .
• Fifty-nine percent of the patients with weight loss and 75.2 percent of these with hypoalbuminemia were on some kind of dietary restriction.

In older, nutritionally high risk adults with diabetes, regular monitoring of blood sugar and adjustment of medication is preferable to dietary restriction or maybe a “no concentrated sweets” prescription.
• The short-term substitution of an everyday diet for a diet increased calorie consumption and failed to cause gross deterioration of glycemic control in an exceedingly study of chronic care patients with type 2 diabetes .

• Make sure that feeding or shopping assistance is accessible, if appropriate. in an exceedingly crossover controlled trial of feeding assistance in institution residents in danger of weight loss, those within the intervention group showed a big increase in daily caloric intake and either maintained or gained weight, whereas those within the control group lost weight.

• Feeding assistance was resource-intensive and required a mean 37 more minutes of staff time per meal .

• Social work support could also be important if inadequate finances are contributing to poor intake.
• Assure that meals and foods meet individual tastes. Suggest offering foods that fit the patient’s ethnic or regional preferences.
• Consider ways to supplement the patient’s diet.
• Increase the nutrient density of food. as an example, increase protein content by adding milk, whey protein (found in many food stores), egg whites, or tofu.
• Increase fat content by adding oil (or other “good fat”) in preparation of sauces, fresh or cooked vegetables, and grains or pasta.
• If weight doesn’t improve, offer daytime snacks between meals.
• Give a daily multivitamin and mineral supplement until the reason behind inadequate intake is set.
• Consider a liquid dietary supplement

Nutritional supplements
A meta-analysis evaluated 55 randomized trials of nutritional supplements containing protein and energy to stop malnutrition in older, high-risk patients.
Studies were generally judged to be of poor quality, because of lack of blinding and intent to treat analysis.
The trials evaluated supplements providing between 175 and 1000 additional kcal/day and between 10 and 36 g protein/day.
Most subjects (45 percent) were hospitalized for stroke; 16 percent were community-based and 10 percent in long-term care facilities.
Nutritional supplementation resulted in modest improvement in percentage weight change (weighted mean difference 1.75 percent, 95% CI 1.2 to 2.3), with slightly greater weight increase in patients reception or in long-term care.
Overall mortality was reduced within the groups receiving nutritional supplement, compared to control, but there was no mortality impact for patients living reception, and no improvement in functional status.
The greatest mortality impact was found in hospitalized undernourished patients who were 75 years or older, and who received supplements with higher calorie content.
Complication rates were lower for hospitalized patients who received supplementation, but there was no change in hospital length of stay.
In another meta-analysis, there was some evidence that volitional nutrient support (VNS) improved survival among malnourished geriatric patients .
Findings were significant for low-quality trials; two top quality trials found benefit for VNS during this population, but the difference from control failed to reach statistical significance.
A randomized crossover trial of organic compound supplements in 41 sarcopenic older adults demonstrated increases in whole-body lean mass at six and 12 months. This study also demonstrated that supplementation led to improved nutrition as reflected by Mini Nutritional Assessment (MNA) scores, improved albumin levels, decreased scores for depression measured by the Geriatric Depression Scale (GDS), and better hand grip strength .
More studies are needed within the sarcopenic geriatric population before aminoalkanoic acid supplementation will be generally recommended in clinical practice .
Appetite stimulants
Use of appetite stimulants (orexigenics) could also be considered, although there are few studies of use of those medications within the older population with weight loss and failure to thrive.
There is inadequate information to work out the suitable use of orexigenics in older adults with cachexia.
The complex interplay between inflammation, catabolism, and nutritional substrate in cachexia demands multimodal interventions that address all three elements.
Megestrol acetate — progestogen , a progestational agent, has been shown to yield weight gain in patients with anorexia and cachexia. progestogen has demonstrated weight gain and improved quality of life for patients with cancer .
In a randomized trial, progestin 800 mg daily for 12 weeks improved appetite and sense of well-being during a group of home residents.
However, weight gain wasn’t found to be significant (>4 lbs) until three months after treatment .
Weight gain was more prominent in residents with elevated cytokine concentrations.
Patients treated with progestin should be watched closely for edema and worsening of congestive failure.
Small studies have also demonstrated impaired function of the corticoadrenal axis ,and increased incidence of deep thrombosis in patients treated with megestrol.
Megestrol may have adverse effects on muscle. in a very randomized trial of exercise training and megestrol in older veterans, subjects who took megestrol had less gain in muscle strength or functional performance.

Dronabinol

Dronabinol has been shown to boost appetite in patients with AIDS; it had been not as effective as megestrol in patients with advanced cancer .
Dronabinol has not been well-studied in older adults. A limited non-randomized trial showed that dronabinol could also be useful for anorexia, weight gain, and behavior problems in patients with advanced Alzheimer disease who were refusing food .

Dronabinol has significant CNS side effects, limiting its use for many older adult populations.

Mirtazapine

Mirtazapine , an antidepressant that ends up in more weight gain than SSRI antidepressants, is often used for management of depression and weight loss in older adults.
However, few studies are specifically performed to judge its impact on weight among older adults with weight loss.
Two studies in rest home residents didn’t show conclusive benefit for mirtazapine over other non-tricyclic antidepressants .

OVERNUTRITION

The National Heart, Lung and Blood Institute clinical guidelines define overweight as a BMI of 25 to 29.9 and obesity as a BMI of 30 or greater .
For the population as an entire, higher body weights are related to increase in all-cause mortality, moreover as morbidity associated with hypertension, dyslipidemia, type 2 diabetes, coronary cardiovascular disease, stroke, gallbladder disease, osteoarthritis, sleep disorder and respiratory problems, and endometrial, breast, prostate, and colon cancers.

Several studies suggest that the link of overweight or obesity to mortality declines over time:
• Data from the Longitudinal Study of Aging found that a comparatively high BMI (30 to 35 for ladies and 27 to 30 for men) was related to minimal excess risk for mortality in adults older than 70 years old .
• A longitudinal study of over 500,000 adults within the US found a decrease within the association of obesity with upset mortality over time .
• Data from several other long-term observational studies, including the Cardiovascular Health Study, the Medicare Current Beneficiary Surveys , and also the National future Care Survey have also found that being overweight doesn’t increase mortality risk for people age 65 years and older.
However, BMI and weight might not be reliable indicators of overweight or obesity in older populations, where normal weight may reflect loss of muscle mass instead of decreased adiposity.
A few studies suggest that being overweight as an older adult is related to increased mortality:
• In a study of men 60 to 79 years within the uk, mortality wasn’t increased for overweight or obese participants as defined by BMI .
• However, mortality risk was increased with increasing waist circumference and with BMI, when data were corrected for differences in midarm muscle circumference. These findings suggest that cardiorespiratory fitness and muscle mass may play a very important role within the relationship between BMI and mortality.
• Another report found a U shaped pattern in women ≥65 years old, comparing mortality across weight quintiles, with lower mortality for ladies within the middle 3 quintiles .
• A J-shaped pattern for BMI and mortality was demonstrated in another study of adults, predominantly men, over age 60.
• In this study, BMI within the overweight range was protective.
Though the mortality risk of obesity may lessen with age, there are still potential metabolic and functional benefits to weight loss within the obese older adults.
Increasing obesity in older adults is related to new or worsening disability and weight loss can improve physical function and quality of life for several older adults.
Recommendations to lose or not has to be individualized to the chance profile of particular patients.
Those who are experiencing significant adverse effects related to obesity (such as pain from osteoarthritis or obstructive sleep apnea) should be encouraged to pursue cautious weight loss, but only within the context of normal exercise and appropriate calcium and ergocalciferol supplementation.
Negative outcomes related to weight loss in overweight older adults include loss of muscle mass and reduce in bone mineral density; both of those could also be mitigated with regular exercise .

MICRONUTRIENT DEFICIENCIES IN OLDER ADULTS
Vitamin B12 deficiency
The prevalence of B12 deficiency in older adults ranges between 10 and 20 percent .
Some persons with low normal serum B12 levels may of course be deficient, with resultant neurologic, psychological, or hematologic disease.
The diagnosis might have to be made by measurement of methyl malonic acid, which is elevated with B12 deficiency.

In the past, a majority of B12 deficiencies were thought to result from factor deficiency.
It is now known that approximately 15 percent of older adults (>60 years) poorly absorb protein-bound B12.
This is a results of malabsorption of the food-protein-B12 complex within the stomach, associated with gastric achlorhydria and infrequently related to atrophic gastritis .
This may be consequent to current or past H pylori infection.
Concern had been raised that folate fortification of foods may mask macrocytic anaemia in those with B deficiency. However, a study using NHANES data for older adults within the post-folate fortification years found that those with B12 deficiency and better folate levels were more likely to be anemic and to own cognitive impairment than patients with normal folate levels .

Given the high prevalence of B12 deficiency and therefore the ease and safety of treatment, some have advocated routinely screening adults over the age of 65 with a serum B complex assay .
However, this policy has not been endorsed in formal screening guidelines for the geriatric population.
Patients with B12 deficiency can generally be treated with oral B12 and will like increasing the intake of B12 in food.
Because B12 malabsorption is common in older adults, with potentially significant effects of B deficiency on the system, individuals >51 years old should take supplements containing antipernicious anemia factor, or eat fortified food products.
it’s prudent to advocate a daily intake of 10 to fifteen mcg .
For food cobalamin malabsorption-induced B12 deficiency, ongoing therapy with 1,000 mcg per day of oral crystalline cyanocobalamin may correct serum B-complex vitamin levels and yield adequate hematological responses .

Vitamin D deficiency
Lack of sun exposure, impaired skin synthesis of previtamin D, and decreased hydroxylation within the kidney with advancing age contribute to marginal cholecarciferol status in many older adults .
additionally, dietary D intake is commonly low in older subjects.
it’s been estimated that approximately one-half of older women consume but 137 international units (units)/day of fat-soluble vitamin from food, and nearly one-quarter consume but 65 units/day .

Inadequate fat-soluble vitamin status has been linked with muscle weakness, functional impairment, depression, and increased risk of falls and fractures .
An observational study during a large integrated healthcare system found an association between low D and increased prevalence of diabetes, hypertension, hyperlipidemia, and peripheral vascular disease .
Lower serum 25-hydroxyvitamin D concentrations in older persons have also been related to a greater risk of future rest home admission .
Patients with calciferol insufficiency can also have relative hypocalcemia and high serum internal secretion (PTH) concentrations; this secondary hyperparathyroidism is attenuated by the administration of fat-soluble vitamin supplements .

Many older adults will have low levels of serum of 25-hydroxyvitamin D levels (<20 ng/mL or 50 nmol/L).
Older individuals at higher risk for cholecarciferol deficiency include those that are institutionalized, homebound, have limited sun exposure, obesity, dark skin, osteoporosis, or malabsorption. Monitoring of serum levels of 25-hydroxyvitamin D (25-OHD) is suggested for those at high risk, with the goal of achieving levels ≥30 ng/mL. Testing at three to four months following initiation of D supplements, if needed, should be done to assure that the target has been achieved.

Increased consumption of dietary sources of viosterol should be encouraged all told older adults.
In 2010, the Institute of drugs (IOM) released a report on dietary intake requirements for calcium and calciferol for normal healthy persons .
The Recommended Dietary Allowance (RDA) of fat-soluble vitamin for adults through age 70 years is 600 IU with the RDA increasing to 800 IU after age 71.

Vitamin D supplementation with cholecalciferol (vitamin D3) in doses of 600 to 800 mg daily is recommended for people with serum 25OHD level within the range of 20 to 30 ng/mL. Some individuals may have higher doses.
Regimens for ergocalciferol supplementation for those with serum 25OHD levels <20 ng/mL are discussed separately

Inadequate intake of calcium
Calcium nutrition is strongly influenced by age. The efficiency of calcium absorption from the canal decreases significantly after age 60 in both sexes.
Individuals between 70 and 90 years old absorb about one third less calcium than do younger adults.
Osteoporosis affects quite 10 million people within the u. s., and causes over 1.5 million fractures within that population every year .

Given the impact of calcium deficiency on cortical bone loss, the adequate intake (AI) reference value for Ca for those >51 years old was increased from 800 (1989 RDA) to 1200 mg/d.
Food sources of calcium and available calcium supplements are shown in tables ( table 3 and table 4 ).
Multivitamin supplementation
Whether multivitamin (MVI) supplementation should be routinely recommended to older adults remains a source of some controversy and confusion.
Many older adults use MVI supplements.
within the 1999-2000 National Health and Nutrition Examination Survey (NHANES), 35 percent of adults within the us used multivitamin-multimineral supplements (MVM) and older adults were more likely than younger groups to use them (OR 1.7, 95% CI 1.3-2.2).
In a longitudinal cohort study of predominantly white older women, the employment of dietary supplements increased significantly between 1986 and 2004 (from 63 to 85 percent of girls reporting use of a minimum of one supplement daily) .

MVM supplementation has been recommended for older adults who are more likely to own compromised nutritional status (such as those within the long run care setting), to assist achieve recommended intakes of certain micronutrients .
evidence, however, provides only weak support for this practice:
• In a study of 263 older adults attending senior centers, nutrient intake was estimated from dietary recalls and reported use of MVM supplementation .
• Subjects who reported taking MVM were calculated to own improved intakes of vitamins E, D, B6, folic acid , and calcium, but were likely to exceed the Tolerable Upper Limit for niacin, folic acid, and antiophthalmic factor.
• In a study of 4384 adults 51 years old and older, supplements improved the nutrient intake of older adults. After accounting for the contribution of supplements, 80 percent or more of users met the estimated average requirement (EAR) for vitamins A, B6, B12, C, and E yet as for folate, iron, and zinc, but not for magnesium.
• However, some supplement users, particularly men, exceeded Tolerable Upper Intake Levels for iron and zinc and atiny low percentage of ladies exceeded the Tolerable Upper Intake Level for antiophthalmic factor .
• A few studies have suggested that MVM might reduce the incidence of infections, and upper tract infections particularly.
• during a systematic review of eight randomized trials of multivitamins and mineral supplements primarily involving older adults, three studies found that MVM reduced the amount of days spent with infection by 17.5 (95% CI 11-24) but analysis of 4 studies showed no impact on the infection rate .
• In an 18-month randomized trial involving 763 institutionalized older adults from 21 long-term care facilities, there was no statistically significant difference within the rate of infections within the supplement and placebo groups .
• In a cohort study of 38,772 older women followed for over 20 years with a mean age of 61.6 at baseline, supplementation with daily multivitamins was related to alittle increase in total mortality (HR 1.06, 95% CI 1.02-1.10) .

Therefore, routine supplementation with multivitamins and minerals isn’t indicated to scale back infections in frail seniors and is probably going not beneficial unless it’s clear that the older adult isn’t meeting his or her micronutrient needs because of low overall intake. The 2006 NIH Consensus Conference on the employment of MVM found evidence insufficient to recommend for or against the employment of MVMs to stop chronic disease for the US population generally .

INFORMATION FOR PATIENTS
UpToDate offers two kinds of patient education materials, “The Basics” and “Beyond the fundamentals.” the fundamentals patient education pieces are written in plain language, at the 5 th to six th grade reading level, and that they answer the four or five key questions a patient might need a couple of given condition.
These articles are best for patients who need a general overview and preferring short, easy-to-read materials. Beyond the fundamentals patient education pieces are longer, more sophisticated, and more detailed.
These articles are written at the ten th to 12 th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to the current topic.
We encourage you to print or e-mail these topics to your patients. (You also can locate patient education articles on a range of subjects by searching on “patient info” and therefore the keyword(s) of interest.)
• Basics topics

SUMMARY and suggestions

• The involuntary loss of quite 5 to 10 percent of an older person’s usual weight during one year is a vital clinical sign related to increased risk for mortality.
• Weight loss should thus be met concernedly and prompt a groundwork for the cause.
• Involuntary weight loss is mostly associated with one or a mix of 4 conditions: inadequate dietary intake, appetite loss (anorexia), muscle atrophy (sarcopenia), or inflammatory effects of disease (cachexia).
• Inadequate dietary intake may relate to social, psychological, medical, and physiologic issues. Depression is that the most prevalent associated condition in several studies, with cancer because the second most typical cause.
• Pro-inflammatory cytokines are common in older adults and are particularly elevated in patients with cachexia.
• Sarcopenia is commonly associated with a discount in testosterone and estrogen and increase in insulin resistance
• Evaluation of weight loss should include serial weight measurements, dietary or appetite assessment, history, physical examination, and screening laboratory studies (CBC, chemistry profile, thyroid studies). Additional studies should be supported findings of the initial evaluation and will include upper GI endoscopy for patients with early satiety or thoracic/abdominal/pelvic CT scan for patients with unexplained ongoing weight loss.
• Treatment should be directed at the underlying cause (ie, treatment for depression) still as dietary modification.
• Nutritional restrictions should be lifted; patients with diabetes may had best with an everyday diet and adequate monitoring.
• High-calorie foods should be provided.

We suggest providing oral nutritional supplementation for patients who don’t regain weight with adjustments in meal preparation and diet ( Grade 2B ). we advise not treating patients with appetite stimulants ( progestogen or dronabinol ) because of marginal benefit and potential side effects ( Grade 2B
• Mortality risk in people over age 70 isn’t significantly impacted by an elevated BMI within the 25.0 to 29.9 range.
• Advice regarding weight loss for the overweight older person should be tailored to the individual, assessing the impact of excess weight on their quality of life, and will include the requirement for normal exercise.
• Vitamin B12 deficiency affects about 15 percent of individuals >60 years within the US and most typically relates to malabsorption of food-protein-B12 complexes.
• Oral B12 supplements, 1000 mcg daily, can usually correct B12 deficiency within the older adult. Daily intake of B12 10 to fifteen mcg, by supplement or fortified products within the diet, is suggested for people >50 years.

• Vitamin D deficiency is additionally common within the older population. viosterol supplements or fortified foods should supply 600 to 800 IU of D per day for older adults. Additionally, 1200 mg/d of elemental calcium should be provided daily.