The Memorial Sloan Kettering Cancer Center GERIATRIC PLAN©: Nutrition

Related Issues:

Diet, weight loss,  fluid balance, hydration, anemia

Why Nutrition is Important:

• Studies have found that 74.6% of women and 67.4% of men aged 65 years or older suffer from many clinical and subclinical syndromes and problems, including anorexia, undernutrition, weight loss, sarcopenia, and cachexia, which are often overlooked  or managed inadequately (Hao & Guo, 2012)
• Poor nutritional status has been associated with increased postoperative morbidity and mortality in surgical patients (Kathiresan et al., 2011)

Normal Age-Related Changes

Decreases in:

• Basal metabolic rate
• Muscles of mastication
• Taste buds
• Immune response of GI tract
• Gastric emptying leading to early satiety
• Disgestive enzymes
• Thirst perception
• Metabolism of drugs

Potential nutritional deficiencies:

• Protein
• Folic acid
• Vitamin B12
• Iron
• Potassium
• Phosphate
• Riboflavin
• Vitamin K
• Vitamin D
• Magnesium

Older adults are at increased risk if they have any of the following:

Conditions

• Chewing impairment/ill-fitting dentures
• Impaired swallowing
• Crohn's disease
• Anorexia/cachexia
• Constipation
• Ulcerative colitis
• Gastric esophageal reflux disease (GERD)
• Peptic ulcer disease
• Diabetes
• Barrett's esophagus
• Poor dental health
• Thyroid conditions
• Dementia (cognitive impairment)
• Diverticulosis/diverticulitis
• Mucosis/stomatitis
• Bowel and bladder issues
• Functional limitations
• Emphysema/COPD
• Psychiatric conditions (depression)
• Congestive heart failure
• Sensory deficits

Medication-Related Risk Factors

• Chronic NSAID use (ulcers and Gl bleeds)
• Chronic laxative use
• Constipation (opioids)
• Increased appetite (steroids, SSRI's)
• Dehydration, electrolyte imbalance (diuretics)

Behavioral Risk Factors

• Social isolation, loneliness, depression
• Financial hardship
• ETOH abuse
• Smoking dependency

Chemotherapy-related Risk Factors

• Mucositis: anthracyclines (doxorubicin, idarubicin), antimetabolites (methotrexate, fluorouracil, capecitabine, cytarabine, pemetrexed), temsirolimus, busulfan, bleomycin, cyclophosphamide
• Metallic taste/taste changes: SFU, cisplatin, nitrogen mustard, vincristine, cyclophosphamide
• Food aversions r/t chemotherapy
• Nausea, vomiting, diarrhea, constipation

Surgery-Related Risk Factors

• Head and neck surgeries
• Gastrointestinal surgeries (altered Gl anatomy)
• Extended NPO status
• Post-operative complications:  nausea, paralytic ileus, constipation, pain,etc.
• Decreased food intake post operatively (food aversions, disruptions of usual meal patterns, environment)
• Potential for catabolic effects of surgery (increased caloric demand post-operatively)

Radiation Risk Factors

• Trismus r/t head and neck RT
• Mucositis
• Esophageal strictures
• Radiation esophagitis and colitis
• Decreased appetite
• Fatigue

Assessment:

1. Screening Questions

• Have you experienced any unintentional weight loss in the last 3 months?
• Have you had a decrease in food intake over the past 3 months (related to loss of appetite, digestive problems, or chewing or swallowing difficulties)?
• Do you have any problems which make it difficult  for you to shop for food, prepare meals or feed yourself? (i.e. physical disability, financial limitations)

2. Observations

• Does the patient look
• Undernourished
• Overweight
• Dehydrated
• Weak or frail
• How does their clothing fit?
• Does patient  have the ability to chew, swallow and control their oral secretions?
• Do they exhibit frequent coughing when taking foods or fluids?

3. Screening Tests

• Calculate BMI
• Mini-nutritional assessment MNA
• Simplified nutritional appetite questionnaire SNAQ
• Nutritional Screening Initiative Checklist

Physical Assessment:

• Standard physical assessment with special attention to
• Skin assessment: dryness, turgor, pallor
• Oral mucosa assessment: dentition, prosthodontics (i.e. dentures, bridges),presence of dryness, gingivitis, mucositis, or thrush
• Abdomen: pain, distention, presence of bowel sounds
• Musculoskeletal functioning, mass and tone
• Presence and condition of any tubes or drains (i.e. PEG, PEJ, nephrostomy, ileostomy etc.)

Nursing Intervention:

1. Monitor weight, recalculate BMI as necessary

2. Monitor dietary intake of foods and fluids:

• Have patient complete a 24 hr (or longer) Dietary Recall/Diary
• Have patient record all food and drink consumed within  specific time frame,
• Review data: total calorie count / protein content
• Note types of foods and patterns of eating / meal times
• Make appropriate dietary suggestions to increase kcal/fluid as needed; capitalize on periods of appetite-mealtimes

3. Review patient appetite and current medications; discuss appropriateness/use of appetite-enhancement medications or changes in current medications with LIP (i.e megace- progesterone, dronabinol)

4. Suggest nutritional supplements (i.e Ensure, Scandishake) and dietary modifications to supplement intake and to address medical conditions (constipation, diarrhea, etc.) as appropriate

5. Assess social and environmental support and refer for assistance as appropriate

6. Monitor labs for dehydration, vitamin deficiency, malnutrition (albumen, electrolytes, Vitamin D,Calcium, Iron Studies, HlAC,TSH (T3 & T4), CBC, CRP and discuss with LIP

7. Coordination/Consults/Referrals:

• Nutrition/Registered Dietician--specialized nutrition evaluation and teaching, dietary suggestions, and supplements
• PT/OT to improve conditioning
• Cardiac/Pulmonary rehabilitation for symptomatic disease
• CSW consult to assist with securing food assistance program and to offer financial, psychological and social support
• VNS for home evaluation/needs assessment
• Primary care MD for ongoing management

Hao, R. & Guo, H. (2012). Anorexia, undernutrition, weight loss, sarcopenia and cachexia of aging. European Review of Aging and Physical Activity 9(2), 119-127.
Kathiresan, A.S., Brookfield, K.F., Schuman, S.I., Lucci, J.A. (2011). Malnutrition as a predictor of poor postoperative outcomes in gynecologic cancer patients. Archives of Gynecology and Obstetrics 284(2), 445-451.

Other helpful resources:

Agarwal, K.  (2014, April 1). Failure to thrive in elderly adults: management. Retrieved from http://www.uptodate.com/contents/failure-to-thrive-in-elderly-adults-management.
Arenson, C., Busby-Whitehead, J., Brummel-Smith, K., O’Brien, J.G., Palmer, M.H., Reichel, W.  (Eds.). (2009). Reichel’s care of the elderly: clinical aspects of aging. New York: Cambridge University Press.
Fass, R. (2014, January 8). Overview of dysphagia, in adults. Retrieved from http://www.uptodate.com/contents/overview-of-dysphagia-in-adults#H17689849.
Heflin, M.T. (2015, July 29). Geriatric health maintenance. Retrieved from http://www.uptodate.com/contents/geriatric-health-maintenance.
Hurria, A. and Cohen, H.J. (2015, May 7). Comprehensive geriatric assessment for patients with cancer. Retrieved from http://www.uptodate.com/contents/comprehensive-geriatric-assessment-for-patients-with-cancer.
Krauss Whitbourne, S. (1996). The aging individual: physical and psychological perspectives. New York: Springer Publishing Company.
Lichtman, S. (2015, August 6). Systemic chemotherapy for cancer in elderly persons. Retrieved from http://www.uptodate.com/contents/systemic-chemotherapy-for-cancer-in-elderly-persons.
Roe, D.A.  (1992). Geriatric nutrition. Englewood Cliffs, N.J.: Prentice Hall.
Ritchie, C.  (2015, October 22). Geriatric nutrition: nutritional issues in older adults. Retrieved from http://www.uptodate.com/contents/geriatric-nutrition-nutritional-issues-in-older-adults​.
Ward, K.T. and Reuben, D.B. (2015, August 6). Comprehensive geriatric assessment. Retreived from http://www.uptodate.com/contents/comprehensive-geriatric-assessment​.