NUTRITION ACROSS THE CONTINUUM INCLUDING AT THE END OF LIFE Bindhu Thomas, M.D., C.M.D Division of Geriatric Medicine and Aging Columbia University College of Physicians and Surgeons

Goal To familiarize the participants with risk factors for compromised nutritional status older adults face as they traverse the continuum of care To familiarize the participants with aspects of nutrition at the end of life, dilemmas, and concepts of palliative, hospice care

A Sobering Trend Line

Objectives Identify 8 main categories of nutritional risk factors Name one risk factor from each category for each venue of care Name 1 difference between palliative and hospice care Give 2 reasons why patients are not referred for Palliative or Hospice Care Things patients with serious illness want?

Homeostasis

Homeostenosis

WHAT IS THE CONTINUUM THE COMMUNITY…….. THE HOSPITAL………… HOMEBOUND………….. THE LONG TERM CARE FACILITY….

Geriatric Nutrition Body weight is a simple screen for nutritional adequacy Avolitional weight loss is predictive of mortality in older adults At high risk for malnutrition 71 % hospitalized patients are at nutritional risk or malnourished Changes with normal aging Diminished organ system reserves Weakened homeostatic controls Increased heterogeneity among individuals

Gastrointestinal System Broad series of changes Symptoms are usually delayed Delayed sx due to the redundancy of overall GI function

GI System Slower production of dentine Root pulp shrinkage Jaw bone density ↓ Taste and Smell ↓ Salivary gland function ↔ Tongue appears larger Esophagus fxn normal Muscular contraction and peristaltic wave decrease Less acid secretion Decreased gastric emptying Liver weight declines Reduction in small intestine surface area Decline in Colonic function Motility to rectosigmoid area not affected Distally ..its slowed Stool frequency declines Hardness increases Diverticula increases Taste and smell decline with rising threshold for salt, sweet , and certain proteins. Tongue appears larger b/c of the loss of bone and tongue musculature. Diverticuli present due to decreased fiber intake and greater pressure in the colonic tissues.

Age Related GI Syndromes Peridontal disease GERD Colon Cancer Constipation : 60% Sx of obstipation: Delirium Nausea Vomiting Gastric empty delay…early satiety Hepatic metabolism Diverticulosis/diverticulitis

Nutritional Risk Factors

PRIMARY AGING Normal, disease-free aging across adulthood Not pathologic in themselves Slight decrease in function in every organ system Menopause Decline in reaction time Thinning and graying of hair HALLMARKS Decreased reserve Heterogeneity among different people Variability within different organ systems

SECONDARY AGING Diseases and syndromes that are more common in older adults Changes due to disease, lifestyle, and environmental factor HEENT CONDITIONS Visual impairment (cataracts, macular degeneration, retinopathy) Decreased auditory acuity Poor dentition GI CONDITIONS Achlorhydria Diverticulosis/itis / Hemorrhoids Neoplasias IBS PULMONARY CONDITION COPD

INTEGUMENT/MUSCULOSKELETAL CONDITIONS DJD Osteoporosis CARDIAC CONDITIONS Cardiac cachexia Severe CHF INTEGUMENT/MUSCULOSKELETAL CONDITIONS DJD Osteoporosis Podiatric concerns NEURO-PSYCH CONDITIONS CVA Dementia Depression Parkinson’s Delirium

Tertiary Aging Psycho-Social, environmental and societal factors occurring more commonly with aging

Lifelong Eating habits Tertiary Aging Isolation Poverty Immobility Caregiving Lifelong Eating habits

NUTRIENT REQUIREMENTS Very difficult to generalize Heterogeneity Extrapolated Based on healthy people NAS/NRC decrease caloric intake by 10% Protein should be .8 – 1 g/kg/d

Nutrient Requirements Calculating Caloric Need Low stress: 20 kcal/kg/d Moderate stress 25-30kcal/kg/d Severe stress 35kcal/kg/d

Nutrient Deficiencies Most often seen in older adults who have other risk factors or who are acutely ill Seen in older adults who live alone in the community, on a budget, and have multiple comorbidities

Nutrient Excess 50% of adults >60 years are now obese Metabolic syndrome Abdominal obesity >102 cm men >88cm women Triglycerides > 150 mg/dl HDL < 40 men, 50 women BP > 130/85 mm Hg Fasting glucose >110 mg/dl

EFFECTS OF NUTRIENT EXCESS Total intake: Obesity, HTN, DM, DJD Vitamin A : Anorexia, xeroses, hypercalcemia Vitamin E : Hemorrhage, GI distress, K metabolism Vitamin C : Diarrhea, renal oxalate calculi, B12 absorption, false negative hemoccult

ALCOHOL Smaller volume of distribution  higher blood levels Increased tissue sensitivityCNS effects Multiple drug-ETOH interactions 7kcal/gm; no other nutritive value

Medication effects on nutritional status MEDICATIONS Medication effects on nutritional status Symptom Medications Anorexia Digoxin, antibiotics, narcotic analgesics Xerostomia psychotropic, anticholinergics diuretics, antihistamines, Diarrhea laxatives, psychotropic, sertraline Nausea, vomiting Digoxin, narcotic analgesics, chemotherapeutic agents, antibiotics, NSAIDs

FLUIDS HYPODIPSIA Decreased vasopressin response Thirst derangement  oropharyngeal sensation  baroreceptor sensitivity  osmoreceptor sensitivity Antidipsogens:  agonists, dopamine antagonists, ANF

Case: Ms. D 86yo woman with PMH DM, HTN, HLD and dementia Previously living in her own apartment with 24hr HHA Fall-broken right hip S/P repair Unable to return home after surgery Discharged to nursing home

Case Episodes of delirium after surgery Unable to walk, mostly in bed or wheel chair Decreased interest in food Readmitted to hospital Declining mental status, but still seems to enjoy visits from family Family is deeply troubled by her not eating

Feeding Difficulties in Advanced Dementia Very common Very difficult for families Do not care about food Resist food Dysphagia Aspiration

PEG Tubes Intended to prevent aspiration Provide nutrition Prevent weight loss 34% of nursing home patients with advanced dementia have PEG tubes 2/3 of these tubes were placed during an acute hospitalization Difficult to study in this population. No RCT looking at PEG tube placement in advanced dementia. However, many observational studies repeatedly show that there is no benefit to PEG tube placement in these patients.

PEG Tubes Do Not Reduce Risk Of Aspiration Oral secretions can still be aspirated Do not reduce risk of regurgitating stomach contents, which can then be aspirated Case control studies identified PEG tubes as a risk factor aspiration pneumonia Jejunostomy is not associated with lower rates of aspiration pneumonia Animal models showed that PEG tube placement may decreases lower esophageal sphincter pressure and increase the risk of reflux

Tube Feeding Does Not Improve Quality of Life Associated with increased risk of development of pressure ulcers Increased use of restraints More frequent ER trips for tube-related problems Within 1 year of insertion, almost 20% of patients required a reinsertion or repositioning of tube Ulcers: Increased immobility from increased restraints. Diarrhea from tube feeds Restraints: Chemical and physical. To prevent pulling out tube

PEG Tube Placement Does Not Improve Survival Risk associated with procedure: 2% mortality rate during procedure 6-24% mortality rate in perioperative period In hospitalized patients with advanced dementia: 50% 6 month mortality with or without PEG tube Median survival after PEG tube placement is 7.5 months No difference in survival seen when comparing PEG tube to no PEG tube in those with recent progression to severe cognitive impairment

Appetite Stimulants: Orexigenics High calorie supplements: Boost Megestrol acetate: Progesterone receptor agonist Appetite stimulant Contraceptive Antineoplastic agent Dronabinol AIDS, Alzheimers, not studied Mirtazapine (Remeron) Cannabinoids Megestrol acetate: Used to treat breast Ca, endometrial Ca, and prostate Ca. Appetite stiumlant doses are 400-800mg/day. Antineoplastic doses are 40-320mg/day

Appetite Stimulants Do Not Improve Outcomes High calorie supplements can increases weight However, no improvement in quality of life, functional status, and survival Lack of evidence supporting use of cannabinoids Mirtazapine may increase weight and appetite, however no evidence supporting its efficacy in the absence of depression Megestrol acetate shows minimal improvement in weight and appetite, but… Not recommended by AGS High doses required for some increase in appetite. Mild increase in prealbumin levels.

Megestrol Acetate: Increased Risk From Side Effects Increase risk of thrombotic events Increased fluid retention Increased risk of death Recently classified as a medication to avoid in older adults Not recommended by American Geriatric Society 6 fold higher risk of DVT with megestrol acetate in nursing home patients vs. those in nursing home not taking megestrol acetate

Supportive Measures Slow hand feeding as tolerated and desired by patient Study showing no difference in survival in demented vs. non-demented patients in long term care getting slow hand feeding Oral feeding promotes socialization between family and patient Treat mealtime as a social event. Encourage families not to feel pressured to have patient eat a certain amount Feed patient food they enjoy. Increase spices to enhance flavor

Supportive Measures Mouth care Ice Chips Patients have decreased salivation at end of life Significant discomfort from dry mouth Ice Chips Treat other causes of feeding difficulties Constipation Depression Xerostomia Mouth care: Oral swabs improve symptoms and are something that caregivers can directly do for patient.

Reality There will come a time when the diet consistencies, orixogenics, supplements, G, J Tubes will start to fail. Body will start shutting down You, as the clinician must anticipate this and prepare the patient and family. Prolonging the inevitable is not quality of life Key is …????

Cancer patients maintain stable condition until brief period of rapid decline and death; this is the model upon which hospice care was constructed to support.

For organ failure, gradual decline will be interspersed with episodes of serious condition, one/the final one, that ends in death.

Dementia/frailty trajectory is long period of marginal condition, terminating in death. This is the one that requires endurance; cognitive failure is part of this. To the extent we address cancer and organ failure health needs, more people will die this way. This is the biggest cause of poverty in old age – especially for the woman who takes off work to care for an elderly spouse.

85% of people in the US will experience one of these trajectories at the “end of life” 20% Cancer 25% Organ Failure 40% Dementia/Frailty Key is …????

DIFFICULT DECISIONS Are we preserving life or prolonging death? When is chemo or radiation therapy palliative in nature and when is it curative? PEG tube placement? Do I want to be a DNR-what is a DNR? IVF’s? Hemodialysis? What is “quality of life”?

Communication with Families Speak with patients and caregivers early about what to expect and course of illness Very high mortality rate in people with advanced dementia similar to those with end stage liver disease or cancer Often patient’s families do not know or understand this Start to talk about palliative and Hospice Care Before the Crisis Talk with patient and family about potential to develop feeding difficulties early well before a crisis occurs and decisions have to be made.

WHO DEFINITION “Palliative Care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification, and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual” …any illness, any age, any location…

Palliative care is the active, total care of patients who are NOT RESPONSIVE TO CURATIVE THERAPY If you are suffering from a chronic illness you are probably receiving palliative care.

Hospice Care Hospice care focuses on improving the quality of life for persons and their families faced with a life-limiting illness. The primary goals of hospice care are to provide comfort, relieve physical, emotional, and spiritual suffering, and promote the dignity of terminally ill persons. Hospice care neither prolongs nor hastens the dying process. Care is palliative (not curative) to control pain and symptoms associated with the terminal illness.

Principles of Hospice Care Affirms life Regards dying as normal process Neither hastens nor postpones death Relives pain and other symptoms Integrates medical, psychological, and spiritual aspects of care Offers a support system to patients and families

When is Hospice Care Appropriate? Patient and Family has opted for palliative care and have decided to forgo curative therapy Medicare guidelines further require that the physician has determined that life expectancy is six months or less if the disease follows its normal course. 2 Doctors have to Confirm the life limiting illness6 months

Who is Eligible for Hospice Care Hospice care is not just for patients dying of cancer Other hospice diagnoses include: End stage heart disease End stage pulmonary disease End stage renal disease End stage liver disease Dementia due to Alzheimer’s Disease and Related Disorders HIV disease Stroke & Coma

Common End Of Life Symptoms Pain Physical Emotional Spiritual Shortness of breath Nausea / vomiting Anorexia / Cachexia Weakness/ fatigue Constipation Delirium

What Do Patients with Serious Illness Want? Pain and symptom control Avoid inappropriate prolongation of the dying process Achieve a sense of control Relieve burdens on family Strengthen relationships with loved ones Singer et al. JAMA 1999;281(2):163-168.

Core Aspects of Hospice Patient/family focused Interdisciplinary Provides a range of services: Interdisciplinary case management Pharmaceuticals Durable medical equipment Supplies Volunteers Grief support

Additional Services Hospices offer additional services, including: Hospice residential care (facility) Inpatient hospice care Palliative care Complementary therapies Specialized pediatric team Caregiver training classes

Hospice Team Members The patient and family/ caregiver The patient’s primary physician Hospice physician Nurse Social worker Chaplain Hospice aide Volunteers Bereavement counselor Additional team members may include dietician, occupational or physical therapist, pharmacist

The Hospice Team Develops the plan of care Manages pain and symptoms Attends to the emotional, psychosocial and spiritual aspects of dying and caregiving Teaches the family how to provide care Advocates for the patient and family Provides bereavement care and counsel for 13 months

Where Hospice is Provided Home Nursing Facility Assisted Living Facility Hospital Hospice residence or unit Prison, homeless shelter – where ever the person is

How Does Palliative Care Differ From Hospice? Non-hospice palliative care Appropriate at any point in a serious illness. It is provided at the same time as life-prolonging treatment. No prognostic requirement No need to choose between treatment approaches. Hospice is a form of palliative care Care for those in the last weeks/few months of life Patients must have a 2 MD-certified prognosis of <6 months Give up insurance coverage for curative/life prolonging treatment in order to be eligible. (Medicare Hospice Benefit: 84% Medicare, 5% Medicaid, 3% uninsured)

Conceptual Shift for Palliative Care Dx Death Medicare Hospice Benefit Life Prolonging Care Old Palliative Care Bereavement Hospice Care Life Prolonging Care New 59

All hospice care is palliative, but not all palliative care is hospice

Barriers to Palliative Care Absence of an advance directive Lack of clarity as to when to refer a patient Physician’s reluctance to make referral Lack of physician’s familiarity with the availability or suitability of hospice Family reluctance to accept palliative care Association of hospice with death Lack of information about the severity of and/or irreversibility of the patient’s illness

Few want heroic measures to prolong their lives Few want heroic measures to prolong their lives. “Subjects who had living wills were more likely to want limited care (92.7%) or comfort care (96.2%) than all care possible (1.9%).” Silveira, NEJM 2010

What Are Advance Directives? A written statement where You are in charge of making your own decisions Wishes, preferences and choices regarding end-of-life health care decisions A tool to help you think through and communicate your choices Documents can be changed anytime You DO NOT need an attorney Documents can help you express your wishes FORMS www.caringinfo.org

Why Do We Need Advance Directives? Your wishes will be known: AUTONOMY Only used if you are unable to express your decisions This can happen to anyone – at any age …even You and Me Give your loved ones the gift of peace of mind – write down your wishes! According to a national survey done in 2004, 88 percent – feel comfortable discussing issues relating to death and dying, However, only 42% have a living will

Advance Directives Health Care Proxy (HCP) = Allows competent adults to appoint an agent to decide about treatment on their behalf if they become unable to decide for themselves. Living Will = A living will is a written advance directive whereby a person communicates treatment choices to be implemented if he or she loses capacity Power of Attorney for Healthcare= Identifies a decision-maker when an individual can no longer make decisions on their own. They must make decisions based on previously expressed wishes of the patient or in the patient's best interests. This signed form must be notarized or witnessed. The medical POA document is different from the power of attorney form that authorizes someone to make financial transactions for you.

Medical Orders for Life-Sustaining Treatment (MOLST) Autonomy : critical element in providing quality end-of-life care (DOH-5003), Medical Orders for Life-Sustaining Treatment (MOLST) Under State law, the MOLST form is the only authorized form in New York State for documenting both nonhospital DNR and DNI orders MOLST is intended for patients with serious health conditions who: Want to avoid or receive any or all life-sustaining treatment; Reside in a long-term care facility or require long-term care services; and/or Might die within the next year.

Medical Orders for Life-Sustaining Treatment (MOLST) Series of conversations between physician and patient Begins with patient if she/he is not cognitively impaired If impaired: look to the Health Care Proxy Surrogate Court Appointed Guardian Spouse Adult children Parent Adult Sibling Close friend or Relative Can be used in a variety of health care settings

It’s about how you want to LIVE Life-Sustaining Treatment Antibiotics Dialysis Laboratory and other diagnostics Hospitalization Artificial Nutrition and Hydration (tube feeding) Organ Donation Cardiopulmonary Resuscitation (CPR) Do-Not-Resuscitate Order (DNR) Palliative Care Hospice

It’s about how you want to LIVE Learn about your options, choices and decisions Implement your advance directive plans Voice your decisions Engage others to complete their advance directives

CONCLUSIONS Older adults face significant challenges to good nutritional status It is vital that we are aware of both the common and uncommon sources and attend to their needs Understand that there will come a time when we have to back away to maintain nutritional status Do not be afraid to discuss Advance Directives Do not be afraid to talk about death/dying when appropriate

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