1. 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

2. 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

3. A Sobering Trend Line

4. 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?

5. Homeostasis

6. Homeostenosis

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

8. 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

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

10. 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.

11. 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

12. Nutritional Risk Factors

13. 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

14. 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

15. 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

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

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

18. 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

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

20. 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

21. 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

22. 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, B absorption, false negative hemoccult

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

24. 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

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

26. 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

27. 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

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

29. 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.

30. 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

31. 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

32. 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

33. 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 mg/day. Antineoplastic doses are mg/day

34. 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.

35. 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

36. 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

37. 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.

38. 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 …????

39. 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.

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

41. 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.

42. 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 …????

43. 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”?

44. 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.

45. 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…

46. 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.

47. 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.

48. 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

49. 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

50. 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

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

52. 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):

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

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

55. 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

56. 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

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

58. 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)

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

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

61. 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

63. 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

65. 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 

66. 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

67. 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.

68. 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.

69. 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

70. 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

71. 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

72. 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

73. References
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