1. The evaluation and management of weight loss in the nursing home patient Elizabeth A O’Keefe BM BCh, Associate Professor of Medicine, Division of Geriatrics, University of Pittsburgh

2. Objectives Develop a rational approach to evaluation of weight loss in the nursing home Develop a rational approach to evaluation of weight loss in the nursing home Discuss the role of tube feeding in nursing home patients Discuss the role of tube feeding in nursing home patients Review the evidence for other management strategies Review the evidence for other management strategies

3. Prevalence of malnutrition in LTC Protein energy under-nutrition 17% to 65% Protein energy under-nutrition 17% to 65% Morley 1995 Morley 1995 Undernourishment in 50% - 85% of USA care home residents Undernourishment in 50% - 85% of USA care home residents Neel 2001, Crogan 2001 In an academic VA nursing home In an academic VA nursing home - 43% lost weight in first month - 70% lost >10# at some point Silver 1988

4. Effects of Malnutrition Increased mortality Increased mortality Increased chance of hospital admission Increased chance of hospital admission Prolonged hospital stay Prolonged hospital stay Frailty Frailty Functional impairment Functional impairment Pressure ulcers Pressure ulcers Increased risk of fractures Increased risk of fractures

5. Effects of Malnutrition Cognitive impairment Cognitive impairment Decreased QOL Decreased QOL Immune deficiency Immune deficiency Anemia Anemia Lethargy Lethargy Depression Depression Edema Edema

6. Under-nutrition and risk of mortality in elderly patients after hospital discharge Liu etal. J Gerontol 2002

7. Weight loss and mortality in LTC 4.6 times more likely to die within the year 4.6 times more likely to die within the year Ryan et al. Nursing 1995 4.4 times as likely to die in 9 months Keller et al. J Am Geriatr Soc 2003 4.4 times as likely to die in 9 months Keller et al. J Am Geriatr Soc 2003 Odds ratio of 14.7 for death in 6 months with 10% weight loss over 6 months Odds ratio of 14.7 for death in 6 months with 10% weight loss over 6 months Murden et al. J Gen Intern Med 1994

8. Triggers for nutritional evaluation Involuntary weight loss of >5% in 30 days or >10% in 180 days Involuntary weight loss of >5% in 30 days or >10% in 180 days Leaving >25% of meals in last 7 days or at two-thirds of meals Leaving >25% of meals in last 7 days or at two-thirds of meals A BMI of 19 or less A BMI of 19 or less Remember that not all weight loss is tissue loss Remember that not all weight loss is tissue loss

9. Evaluation of weight loss Medical and psychiatric illnesses Medical and psychiatric illnesses Individual factors Individual factors Institutional factors Institutional factors Medications Medications

10. Medical and psychiatric illness Dementia Dementia CHF CHF COPD COPD ESRD ESRD Cancer Cancer Diabetes Chronic infection Constipation Dysphagia Depression

11. Individual factors Poor vision Poor vision Poor dentition Poor dentition Sensory loss (taste and smell) Sensory loss (taste and smell) Poor posture Poor posture Poor manual dexterity Poor manual dexterity Dependence on others Dependence on others Social factors including abuse Social factors including abuse

12. Institutional factors Unappetizing diet Unappetizing diet Failure to help eating Failure to help eating Inadequate staff Inadequate staff Inadequate staff training Inadequate staff training Poor dining environment Poor dining environment Leaving resident in bed all day Leaving resident in bed all day Failure to detect and treat weight loss Failure to detect and treat weight loss

13. Medications associated with weight loss in elderly Amiodarone Amiodarone ACEIs ACEIs Digoxin Digoxin Diuretics Diuretics Metformin Metformin Anti-epileptics Anti-epileptics Narcotics Potassium SSRIs Theophylline Anticholinesterase inhibitors Iron

14. Assessment of weight loss Serial weights Serial weights Food percentages Food percentages Albumin/pre-albumin Albumin/pre-albumin Hemoglobin Hemoglobin Fluid status Fluid status Anthropometric measures and BMI not useful Anthropometric measures and BMI not useful

15. Position of the American Dietetic Association “Liberalization of the diet prescription can enhance both QOL and nutritional status in older adults in long-term care”

16. Enhancing food intake Eating environment Eating environment Positioning at mealtimes Positioning at mealtimes Liquid supplements Liquid supplements Between meal snacks Between meal snacks Adding nutrients to foods Adding nutrients to foods Flavor enhancers Flavor enhancers Favorite foods Favorite foods

17. Micronutrient deficiencies Typical accredited institutional menu cycle (2000kcal/day) does not provide adequate levels of vitamins and minerals to enable older adults to meet RDAs Typical accredited institutional menu cycle (2000kcal/day) does not provide adequate levels of vitamins and minerals to enable older adults to meet RDAs Deficient in Vitamin E, pantothenic acid, calcium, zinc, copper and manganese Deficient in Vitamin E, pantothenic acid, calcium, zinc, copper and manganese LTC residents typically consume <1500kcal LTC residents typically consume <1500kcal Higher RDAs for older adults Higher RDAs for older adults Wendland et al. JAGS 2003

18. Prevention of weight loss in dementia residents Interventional and control sites Interventional and control sites 9-month baseline, 9-month intervention and 12-month post-intervention periods 9-month baseline, 9-month intervention and 12-month post-intervention periods Intervention was increased dietitian monitoring and enhanced menus Intervention was increased dietitian monitoring and enhanced menus Keller et al. JAGS 2003

19. Prevention of weight loss in dementia residents InterventionControl Weight gain >5% 27.3%6.8% Weight loss >5% 6.1%36.4% Average weight change (%) 4.8%-4.5% Dietitian time 533 minutes 18 minutes Keller et al. JAGS 2003

20. “Family-style” mealtimes Cluster randomized trial in 5 Dutch nursing homes Cluster randomized trial in 5 Dutch nursing homes 178 non-demented residents 178 non-demented residents 6 months 6 months Intervention units assigned “Family-style” (FS) Intervention units assigned “Family-style” (FS) Control units continued with pre-plated meals (C) Control units continued with pre-plated meals (C) Kristel et al. BMJ 2006

21. Outcomes Change (FS) Change (C) Difference in change (CI)* QOL (0-100) 0.4-5.0 6.1 (2.1to 10.3) Fine motor function -0.5-2.1 1.8 (0.6 to 3.0) Body weight (kg) 0.5-1.1 1.5 (0.6 to 2.4) Energy (kJ) 481-420 991 (504 to 1479) *Adjusted for age, LOS, sex, nursing home and cluster effect of units

22. Oral supplements in LTC Stabilization of weight loss/slow regain over 9 months Stabilization of weight loss/slow regain over 9 months Johnson et al. J Am Geriatr Soc 1993 In France, malnourished patients gained about 1.5 kg over 60days In France, malnourished patients gained about 1.5 kg over 60days Lauque et al. Age Ageing 2000 Randomized double-blind placebo study in demented patients with supplement between meals: OS gained 1.4±2.4kg: Control lost 0.8±3.0kg Randomized double-blind placebo study in demented patients with supplement between meals: OS gained 1.4±2.4kg: Control lost 0.8±3.0kg Wouters-Wesseling et al. Eur J Clin Nutr 2002

23. Oral supplements (OS) in LTC Not given as often as prescribed Not given as often as prescribed Staff spend minimal time assisting residents consuming them Staff spend minimal time assisting residents consuming them Minimal calories received from OS Minimal calories received from OS - average 144 calories/day (between meals) - average 230 calories/day (with meals) Kayser-Jones. JAGS 2006

24. Oral supplements (OS) in LTC Often associated with significant reductions in “total energy, protein, fat, water, fiber, and many vitamins and minerals, in the habitual diet Often associated with significant reductions in “total energy, protein, fat, water, fiber, and many vitamins and minerals, in the habitual diet Reduction in appetite (if given with, or between, meals) Reduction in appetite (if given with, or between, meals) 3 European studies showed weight gain and improvement in nutritional status 3 European studies showed weight gain and improvement in nutritional status

25. Oral supplements (OS) in LTC Supplements should not be used as a substitute for food and nursing care

26. The role of appetite stimulants in nursing home residents with weight loss

27. Megestrol acetate 69 VA NH patients with wt loss >5%, or 20% below ideal body weight 69 VA NH patients with wt loss >5%, or 20% below ideal body weight Randomized, double-blind, Megestrol 800mg/day vs placebo for 12 weeks Randomized, double-blind, Megestrol 800mg/day vs placebo for 12 weeks At 12 weeks, appetite, well-being and enjoyment of life improved but no wt gain At 12 weeks, appetite, well-being and enjoyment of life improved but no wt gain At week 20, significant wt gain in treatment group of 2.45kg vs. -0,4kg in placebo At week 20, significant wt gain in treatment group of 2.45kg vs. -0,4kg in placebo Megestrol failed to increase weight in a frail subset Megestrol failed to increase weight in a frail subset Yeh. JAGS 2000

28. Concerns about use in LTC Frail patients least likely to respond Frail patients least likely to respond More useful with high cytokine levels More useful with high cytokine levels Need to make sure patients have access to food/adequate feeding Need to make sure patients have access to food/adequate feeding Side effects include fluid retention and-- Side effects include fluid retention and-- Thromboembolism with rates of DVT in NH patients reported from 4.9% to 32% Thromboembolism with rates of DVT in NH patients reported from 4.9% to 32%

29. Dronabinol Synthetic tetrahydrocannabinol Synthetic tetrahydrocannabinol Reduces nausea, improves appetite and weight gain in AIDS Reduces nausea, improves appetite and weight gain in AIDS Placebo-controlled, crossover study in 15 Alzheimer’s patients - more weight gain in Rx group, possibly due to decrease in disturbed behavior Placebo-controlled, crossover study in 15 Alzheimer’s patients - more weight gain in Rx group, possibly due to decrease in disturbed behavior Side effects include delirium, somnolence, ataxia Side effects include delirium, somnolence, ataxia Expensive Expensive Volicer. Int J Geriatr Psychiatry 1997

30. Mirtazapine NA and 5-HT properties NA and 5-HT properties Low dose (15mg) is associated with increased appetite, weight gain and improved sleep (potent H 1 antagonist) Low dose (15mg) is associated with increased appetite, weight gain and improved sleep (potent H 1 antagonist) Safety in non-depressed elderly unknown Safety in non-depressed elderly unknown

31. Retrospective chart review in depressed NH patients Goldberg. JAGS 2002

32. Randomized, double-blind comparative studies In an 8-week study (n=246) comparing wt gain on mirtazapine and paroxetine: 11% gained wt (mean 1.7kg) on mirtazapine vs. none on paroxetine In an 8-week study (n=246) comparing wt gain on mirtazapine and paroxetine: 11% gained wt (mean 1.7kg) on mirtazapine vs. none on paroxetine In a 6-week study (n=150) comparing wt gain on mirtazapine, trazodone and placebo, wt gain (mean 1.3kg) seen with mirtazapine only In a 6-week study (n=150) comparing wt gain on mirtazapine, trazodone and placebo, wt gain (mean 1.3kg) seen with mirtazapine only Schatzberg. Am J Psychiatry 2002 Halikas. Hum Psychopharmacol. 1995

33. Antipsychotics No significant weight changes seen in a trial comparing varying doses of olanzapine vs. placebo to manage behavior in patients with Alzheimer’s No significant weight changes seen in a trial comparing varying doses of olanzapine vs. placebo to manage behavior in patients with Alzheimer’s Street. Arch Gen Psychiatry 2000

35. Tube feeding in advanced dementia “To PEG or not to PEG that is the question?”

36. Demographics of PEG PEG placement in Medicare beneficiaries was increasing: PEG placement in Medicare beneficiaries was increasing: - 81,105 in 1991 - 121,000 in 1995 34% of nursing home residents with advanced cognitive impairment in 1999 had PEG 34% of nursing home residents with advanced cognitive impairment in 1999 had PEG

38. Nursing home resident characteristics associated with PEG Age: 90 years +1.00 Age: 90 years +1.00 65-69years1.32 (1.27-1.38) Men1.15 (1.14-1.18) Men1.15 (1.14-1.18) Race: White1.00 Race: White1.00 Black1.55 (1.51-1.58) Absent:DNR1.07 (1.06-1.10) Absent:DNR1.07 (1.06-1.10) Living will1.32 (1.28-1.35) Alzheimer’s 1.37 (1.34-1.40) Present: CVA1.84 (1.82-1.86) Present: CVA1.84 (1.82-1.86) Mitchell. JAMA 2003

39. Facility characteristics associated with PEG Urban location1.14 (1.11-1.16) Urban location1.14 (1.11-1.16) For profit 1.09 (1.06-1.12) For profit 1.09 (1.06-1.12) >80% Medicaid beds1.00 (0.97-1.03) >80% Medicaid beds1.00 (0.97-1.03) Residents with DNR: Residents with DNR: >80%1.00 <10%1.67 (1.54-1.80) No dementia unit1.11 (1.07-1.15) No dementia unit1.11 (1.07-1.15) No NP or PA on staff1.07 (1.04-1.10) No NP or PA on staff1.07 (1.04-1.10) Mitchell. JAMA 2003

40. State Variation in Feeding Tube Use Teno. JAMA 2002

41. Medicare costs for PEG PEG placement ($2,200) PEG placement ($2,200) ER visits and hospital admissions for tube- related complications ($2,449 in first year) ER visits and hospital admissions for tube- related complications ($2,449 in first year) Skilled nursing benefits for 100 days Skilled nursing benefits for 100 days Overall care plan may be more aggressive Overall care plan may be more aggressive From the Medicare perspective tube feeding in advanced dementia is associated with high costs and no demonstrable health benefits From the Medicare perspective tube feeding in advanced dementia is associated with high costs and no demonstrable health benefits Mitchell. JAGS 2003

42. Medicaid costs for PEG PEG decreases nursing time for feeding and giving meds (15-30 minutes/day vs 45-90) PEG decreases nursing time for feeding and giving meds (15-30 minutes/day vs 45-90) Additional cost of enteral feed/day is $3.15 Additional cost of enteral feed/day is $3.15 Reimbursement for totally dependent patients with PEG is $190/day vs $151 no PEG Reimbursement for totally dependent patients with PEG is $190/day vs $151 no PEG From the Medicaid perspective there is a potential fiscal incentive to tube feed persons with advanced dementia From the Medicaid perspective there is a potential fiscal incentive to tube feed persons with advanced dementia Mitchell. JAGS 2003

43. Unaware of hunger or fail to respond to it Unaware of hunger or fail to respond to it Refuse to open mouth or spit food out Refuse to open mouth or spit food out Chew repetitively and hold food in mouth Chew repetitively and hold food in mouth Fail to initiate the swallowing reflex Fail to initiate the swallowing reflex Swallow ineffectively and aspirate Swallow ineffectively and aspirate Net result is weight loss, dehydration and inability to give medication Net result is weight loss, dehydration and inability to give medication Eating problems in dementia

44. What do we hope to achieve? To prolong life To prolong life To prevent malnutrition To prevent malnutrition To prevent aspiration To prevent aspiration To improve functional status To improve functional status To heal pressure ulcers To heal pressure ulcers To make the patient more comfortable To make the patient more comfortable Hospital discharge Hospital discharge

45. Mortality data in elderly after PEG placement

46. Mortality in patients hospitalized with advanced dementia Meier. Arch Int Med 2001

47. PEG-related complications Mortality, major and minor complication rate of procedure 1%, 3% and 13% Mortality, major and minor complication rate of procedure 1%, 3% and 13% Subsequent complication rate 34% - 70% Subsequent complication rate 34% - 70% Tube leaks, blockage and local infection Tube leaks, blockage and local infection Tube migration Tube migration Aspiration pneumonia in up to 30% Aspiration pneumonia in up to 30% Gastric distension Gastric distension Diarrhea Diarrhea Hyperglycemia Hyperglycemia

48. Negative aspects of PEG placement Denial of pleasure from eating Denial of pleasure from eating Social isolation Social isolation Increased use of restraints Increased use of restraints Increased stool and urine production Increased stool and urine production Prolonging life without quality Prolonging life without quality May necessitate nursing home admission May necessitate nursing home admission

49. Nutritional Interventions in the Treatment of Pressure Ulcers AuthorSettingInterventionOutcome BreslowLong-term care 24% protein vs 14% protein enteral feeding Greater healing with higher protein Chernoff Long-term care 25% protein vs 17% protein enteral feeding Greater healing with higher protein ter RietLong-term care Vitamin C 50 mg vs 1000 mgNo difference in healing NorrisLong-term care Zinc sulfate 200 mg TIDNo difference in healing Henderson Long-term care Enteral feedingNo difference in prevalence at 3 mo MitchellLong-term care Enteral feedingNo difference in prevalence after 2 y

50. Tube feeding in patients with advanced dementia “The widespread practice of tube feeding should be carefully reconsidered, and we believe that for severely demented patients the practice should be discouraged on clinical grounds” Finucaine TE et al. JAMA 1999

51. Rethinking the role of tube feeding in patients with advanced dementia “ There is a pervasive failure - by both physicians and the public - to view advanced dementia as a terminal illness, and there is a strong conviction that technology can be used to delay death” Gillick MR. N Engl J Med 2000

52. Decision-maker expectations

53. Visual analog ratings Condition Initial (survivors) Initial (deceased) 3 month (survivors) Nutrition9.26.32.8* Discomfort5.73.53.7* QOL6.37.34.3 Difficulty feeding 7.07.73.0 SatisfactionN/AN/A1.7 Where 1 is the best outcome and 10, the worst. * = p<0.05

54. Thoughts…… PEG placement in advanced dementia appears to benefit the family more than the patient PEG placement in advanced dementia appears to benefit the family more than the patient Is it ethically justifiable to submit someone to an invasive procedure of no proven benefit to relieve the suffering of their family? Is it ethically justifiable to submit someone to an invasive procedure of no proven benefit to relieve the suffering of their family? Is this a justifiable use of healthcare resources? Is this a justifiable use of healthcare resources? How can we improve counseling about PEG placement to address this issue? How can we improve counseling about PEG placement to address this issue?

55. An approach to counseling about PEG tube decisions

56. Do #1 Meet with the family to discuss the overall prognosis and define expectations Meet with the family to discuss the overall prognosis and define expectations

57. Do #2 Review advance directives Review advance directives

59. Do #3 Discuss likely outcomes after PEG Discuss likely outcomes after PEG

60. Do #4 Review possible complications and negative factors of long-term feeding, not just of the procedure itself Review possible complications and negative factors of long-term feeding, not just of the procedure itself

61. Do #5 Discuss concerns about thirst and hunger Discuss concerns about thirst and hunger

62. Do #6 Respect cultural and religious differences Respect cultural and religious differences

63. Do #7 Discuss alternatives to PEG feeding Discuss alternatives to PEG feeding

64. Don’t #1 Leave the discussion too late Leave the discussion too late

65. Don’t #2 Suggest a “trial” of PEG feeding Suggest a “trial” of PEG feeding

66. Don’t #3 Order a PEG in someone with impaired gastric emptying Order a PEG in someone with impaired gastric emptying

67. Don’t #4 Try and impose your values on patients or families Try and impose your values on patients or families

68. Decision tree for PEG Skelly: Curr Opin Clin Nutr Metab Care2002

69. Management of weight loss Multidisciplinary approach Multidisciplinary approach Counsel patients and families Counsel patients and families Address dietary preferences, texture, oral factors, social issues Address dietary preferences, texture, oral factors, social issues Address swallowing dysfunction Address swallowing dysfunction Make sure someone is feeding the resident Make sure someone is feeding the resident

70. Management of weight loss Control medical illness Control medical illness Treat depression Treat depression Reduce medications!!!! Reduce medications!!!! Dietary supplements Dietary supplements Rarely consider appetite stimulants Rarely consider appetite stimulants Tube feeding not a viable option in most cases Tube feeding not a viable option in most cases

71. Conclusions Weight loss in the NH is complex Weight loss in the NH is complex Important to identify residents at high risk Important to identify residents at high risk Documentation is critical Documentation is critical Accept that weight loss often occurs at the end-of life Accept that weight loss often occurs at the end-of life May be more important to focus on QOL May be more important to focus on QOL