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Pharmacological Treatment of Involuntary Weight Loss in the Senior Patient: A New Approach

Malnutrition and Involuntary Weight Loss in the Senior Patient

Dr. David R. Thomas, MD, CMD, FACP, AGSF, Professor of Medicine, Division of Geriatric Medicine, St. Louis University Health Sciences Center, St. Louis, Missouri, described the causes and evaluation of undernourishment in residents of long-term care facilities. Weight loss is “one of the chief factors associated with mortality in long-term care,” said Dr. Thomas. About 4% to 54% of patients in nursing homes are undernourished, he said.

Dietary standards result in nursing homes feeding each resident about 2200 calories daily, whereas average daily calorie intake for community-dwelling older adults is about 1600. “So we are actually giving people incredibly more food than the average elderly person consumes,” Dr. Thomas said. Although records may indicate that every resident eats all their food, this is almost certainly not the case, he said.

Why do older people consume too little when they are provided with more than enough food? Several mechanisms may explain this. The relaxation of the stomach that occurs with nitric oxide in the presence of food is not the same in the elderly as in younger people. This results in early satiety, Dr. Thomas explained. Decreased testosterone levels, which occur in the majority of aging adults, also produce a cascade of effects leading to reduced food intake, he said. This is known as the anorexia of aging. Researchers are just beginning to understand how cytokines can lead to lower circulating levels of albumin and cholesterol. Effects of cytokines “make a patient sometimes look like they are malnourished when in fact they may not be,” he said.

There are 3 types of weight loss in the nursing home, Dr. Thomas said. Firstly, there are starvation patients. These patients should respond to refeeding. Cachectic patients, another category, often do not respond to increased calories “because the problem is not the lack of food, it is the inability to use it.” Cachexia is mediated by cytokines and associated with chronic inflammatory disease. Sarcopenia, loss of muscle mass without weight loss, occurs particularly in elderly males due to the decreases in testosterone and growth hormone that accompany age, immobility, or severe illnesses. These three classifications can overlap in an individual.

Dr. Thomas provided a structured diagnostic approach to evaluate undernourished patients (summarized by the mnemonic in Table 1). Elements include:
Ability to eat or to feed oneself: Many medical conditions common in nursing homes interfere with the eye-hand coordination required to feed oneself, or with swallowing (e.g., stroke, Parkinson’s disease, arthritis). Providing assistance is ineffective as long-term care facility aides spend an average of 7 minutes feeding a patient, Dr. Thomas said. In contrast, a caregiver at home with an Alzheimer’s patient might spend 90 minutes in the same task. Patients with motor difficulties can be referred for occupational or physical therapy, or for a swallowing evaluation, he said. Some may require dental evaluation.

Problems with the food: Restricting fat and salt in the diet can make institutional food even more unpalatable. “This has led us in our nursing homes to simply abandon therapeutic diets,” Dr. Thomas asserted. Policy now requires contacting the medical director before implementing a therapeutic diet; no such requests have been made, he said.

Medical conditions can increase protein-energy requirements. These include apathetic hypothyroidism, chronic obstructive pulmonary disease (COPD), congestive heart failure, infections, malabsorption syndrome, pressure ulcers, burns, fractures, Parkinson’s disease, rheumatoid arthritis, and elevated levels of circulating cytokines. Adding nutritional supplements is ineffective, he said. Enteral and intravenous nutritional support may help in a limited number of cases.

Anorexia can result from drugs or psychological problems. The list of potentially culpable pharmacologic agents is so long that essentially “any drug you give a patient can cause anorexia,” said Dr. Thomas. Therefore, “pharmacy review is one of the critical key first steps in the management of anorexia and weight loss.”

Psychological issues.
Depression is the single most important cause of anorexia in long-term care. Treating the depression generally increases appetite, he said. Other possible psychological causes of anorexia are dementia, late-life paranoia or mania, and anorexia nervosa. Again, the appropriate intervention is treating the psychological problem.

Physician awareness. Educating physicians about nutrition can improve management of malnutrition, he said. Problems with nutrition often are “not on their horizon,” Dr. Thomas said.

Clinical Guidelines to Prevent and Manage Malnutrition in Long-Term Care

Armon B. Neel, Jr, PharmD, CGP, FASCP, President, MedicationXpert in Griffin, Georgia, noted that good nutrition is essential for good drug therapy. This is because most drugs are highly protein-bound. Patients with low levels of albumin have “more free drug in the system” and may display symptoms of toxicity.

Evaluation for undernourishment should include assessing the medical record, talking with the nurse and certified nurse assistant and interviewing the patient directly (Table 2). Dr. Neel stressed the importance of visiting the patient directly to gather information rather than relying on charts. “If you can’t believe they eat 100% of the food, there are other things in (the chart)… that you can’t believe,” he pointed out.

Pharmacists can recommend serving finger foods which residents can handle themselves, rather than only pureed food. Another option is to supplement patients on pureed diets with a product called Epulor by VistaPharm, which provides 330 calories in 45 cc. Some patients may lose weight on pureed diets because the practice of adding water to facilitate pureeing lowers calorie count by roughly 50%, he said. Adding broths and milk to the diet can maintain calorie count for patients who require a liquid consistency, he said. Testing albumin levels before and after interventions can provide some measure of success.

High-normal laboratory values for chlorine and sodium can suggest near-dehydration in a patient, he said. Dehydration can lead to constipation, which reduces interest in food, he said. Other problems for which to screen include inactivity (bedridden patients consume less food) and mental status. If patients need help with eating, asking family or friends to assist may address the problem.

If the pharmacist suspects depression or psychological difficulties, he or she can encourage the nurse to use an appropriate assessment tool. The request, and the results of the test, should be communicated to the physician and written in the patient care plan.

Skin damage also can affect appetite, Dr. Neel said. Patients who are thin or not ambulatory are at risk for skin abrasions, especially if they are already undernourished. “We want to use T-shirt type material on that bed, or take the sheet undone around the sides and let the sheet move with the patient” to prevent skin abrasions, he said.

Dizzy spells, nausea, and lethargy interfere with eating and often result from overmedication, he said. “We…stand at the door of the dining room and watch the patients as they come in to eat,” Dr. Neel said. Patients whose heads are bent downward often are overmedicated, and require medication evaluation.

In undernourished COPD patients, consider adding a fat module supplement rather than a carbohydrate module supplement, Dr. Neel said. Patients with COPD “can’t get rid of the carbohydrates they have. The CO2 is a byproduct of carbohydrate metabolism,” he pointed out.

He referred attendees to the Clinical Guide to Prevent and Manage Malnutrition in Long-Term Care, developed by the Council for Nutrition and supported by the American Dietetic Association. The guidelines, available at www.ltcnutrition.org, include nurse checklists and assessment tools that can be downloaded.

 

New Approaches to Assessing Orexigenic Agents

John E. Morley, MB, BCh, Dammert Professor of Gerontology and Director, Division of Geriatric Medicine, St. Louis University Health Sciences Center in Missouri, reviewed use of medications that stimulate appetite.

In persons leaving most of their food on the plate, glyceral trinitrate or isosorbide dinitrate can help by replacing the nitric acid missing in older people. Without nitric acid, early satiety can occur so that patients have little appetite.

Intraduodenal infusion of carbohydrate supplements increase appetite in older people. Supplements should be given 1 hour before a meal to be effective, he said. If they are provided at mealtime, as is done in many nursing homes, “the person just eats that much less of their meal,” he said. Fat supplements are less effective because they lead to increased levels of cholecystokinin.

Proper pain management also improves eating, Dr. Morley said. “If you make sure that the medications for pain are written around the clock, you will find people eat better,” he explained. Once this and other medication problems (as discussed by Dr. Thomas) are addressed, “then depression becomes very important,” he said. Mirtazapine is the agent most commonly used to treat depressed older persons with anorexia. Electroconvulsant therapy is the treatment of choice for severe weight loss associated with depression, he said.

Anabolic agents
Dr. Morley recommended testosterone as the first choice among anabolic agents. There is some suggestion that other anabolic steroids may cause renal failure in persons with severe heart failure. Consider increasing food intake and physical activity before adding testosterone in patients losing weight, he
advised. The Council on Nutrition recommends using anabolic steroids only to treat sarcopenia, not in cases of anorexia. Use of the antiserotonergic agent cyproheptadine is supported by only one questionable study, and can cause delirium, he said.

Treatment with a low-dose testosterone gel in older people who were borderline hypogonadal has led to markedly increased lean body mass and decreased fat mass, he said. Testosterone administration also can improve functional status, Dr. Morley said. He cautioned attendees to use a physiologic dose of testosterone from a gel rather than a higher dose delivered by injection.

Potential problems with testosterone in the elderly include its inability to stimulate appetite, its masculinization effects (especially in females), fluid retention, hepatotoxicity, and prostate cancer. Behavior problems are theoretically possible but “we haven’t seen (them),” he said. Contrary to the belief of some, normalizing testosterone levels usually does not lead to residents initiating sexual abuse. In fact, it may cause this behavior to extinguish, he said.

Dr. Morley advised against using growth hormone in older patients, noting that it has not been shown to increase strength and has serious side effects.

Orexigenic agents
Megestrol acetate and dronabinol are available for use in long-term care residents who are not depressed and in whom other interventions have failed. Most studies with the progestational agent megestrol have been conducted in persons with cancer or AIDS. “The reason in these patients that you see positive results is because of the excess cytokine(s)” associated with these conditions, he said.

Megestrol does not work as well in males, partly because it causes testosterone in men to drop “to almost nothing,” he said. Men receiving megestrol must also be given testosterone, he said. Megestrol generally is well tolerated but is associated with hyperglycemia, once sufficient weight has been gained. Because one report noted deep vein thrombosis with megestrol, never give it to a bed-bound, immobile patient, he said. Additionally, never use the drug for longer than 3 months, due to risk of adrenal suppression. “I haven’t said ‘Don’t use (megestrol),’ I have said, ‘Use it properly,’ ” he added.

Dronabinol, a cannabinoid, increases appetite, improves taste sensation, is an antinausea agent, reduces pain, and enhances general well-being. Dr. Morley recommended it as “the ideal palliative care drug.” In the elderly, start with 2.5 mg prior to bedtime. After 1 week, move to 2.5 mg before supper. If there is no response after 2 weeks, use 2.5 mg before supper and lunch. “In older patients we don’t go much above 2.5 twice a day,” he said. It should be used early when weight loss occurs without an obvious cause, in order to stimulate appetite.

Other orexigenics include oxoglutarate, which is available in Europe and “seems to work fairly well,” he said. Those in development include cholecystokinin antagonists, ghrelin agonists, MSH antagonists, and cytokine antagonists. “Very few of these are going to increase appetite as well as some of the drugs we have,” he said.

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