CASE STUDY NO.

3
Ali Quinn and Jia Lu Dietetic Interns | Fall 2013

QUESTIONS: 1. Briefly define the following terms: Cachexia: Cachexia is wasting syndrome described as a loss of weight, muscle atrophy, fatigue, weakness and significant loss of appetite in an individual who is not trying to lose weight. Edentulous: Lacking teeth; being toothless Anergy: A term in immunobiology that describes a lack of reaction by the bodys defense mechanism to foreign substances. The immune system is unable to produce a response against a specific antigen. Anorexia: Anorexia is characterized by low body weight, inappropriate eating habits, obsession with having a thin figure and fear of gaining weight. In older populations anorexia is unintentional and associated with a low body weight. Alzheimers Disease: Alzheimers is the most common form of dementia, a general term for memory loss and other intellectual abilities serious enough to interfere with daily life. 2. Determine Mr. Ds IBW and his percent his percent of IBW. Please show work for all calculations (Appendix A, Tables 7 and 8) Height: 60 Weight: 133 lb 5 = 106 + (6 x 12) = 178 lb IBW %IBW: Actual weight/IBW x 100 = 133 #/178# x 100 = 74.7% IBW = moderate deficit 3. Calculate Mr. Ds BMI and interpret the results. BMI: Wt in kg/ ht in m2 = 133 / 2.2 / 72x.0254 = 60.45/1832 = 60.453.35 = 18.09 Mr. Ds BMI is 18.09; it is classified as underweight and is associated with increased risk of disease. 4. List the lab values affected by hydration and explain why? The lab values affected by hydration status are BUN (deficiency), serum Calicum, Chloride, hematocrit, hemoglobin, total protein, Sodium and Ferritin. The values of the labs listed above are affected by hydration status because the higher the water deficit (dehydration) the more concentrated the solutes become per dL. 5. Calculate Mr. Ds TLC. TLC = WBC x %lymphocyes/100 4.7x103 x 19/100 = 8.93 x 102 or 893 6. List each lab value that suggests nutritional deficiency. Identify the nutritional deficiency in each case and explain how the circumstances in Mr. Ds history contributed to each deficiency.

Mr. Ds lab indicated that his protein intake is low (albumin, TP); his low Hgb/Ht levels reflect he is anemic. The low levels may be related to his diagnosis of cachexia, inadequate oral intake, anorexia and his refusing to use his dentures thus reducing adequate intake. 7. Taking multiple medications is a problem that is common with the elderly. Not only does this create possible diet-drug interactions, but it is expensive. Considering many elderly live on fixed incomes they may be left with insufficient funds for food they need. Find out if there are any programs in your area that provide assistance for these problems and discuss. There are federal programs, such as SNAP or CAL Fresh can help seniors with supplementing their income to buy groceries if the individual is independent with daily activities. Independent seniors may also use food pantries located around the city. For example, Fresno States Bulldog Pantry provides supplemental groceries to residents in the Fresno State community. However if the senior is homebound, the Fresno-Madera Area on Aging Agency (FMAAA) provides meals to seniors and staples. In addition, West Fresno Health Care Coalition can assist with services that can help him get new dentures and help pay for medication. 8. Diet-drug interactions are important in any nutritional assessment. The medications a person has to take and the effects these medications have on nutrient availability must be considered and planned for. Therefore, it is necessary to be familiar with the more common medications. Look up each of the following drugs mentioned in the cause study and indemnity their action. Using the table below, identity those that could have the following complications.
DRUG ACTION N/V CONSTP. DIARRHEA ANOREXIA

HALDOL Antagonizes dopamine D2 receptors NORPACE Stabilizes membranes, depresses action potential phases MOM Laxative, antacid; neutralizes gastric acidity, cases water retention in stool PEPCID Anti-ulcer; selectively antagonizing H2 receptors (hyperactivity) MOBIC Anti-arthritic; exact mechanism of action is unknown. AMBIEN Sleep aid; interacts with GABA benzodiazepine receptor complexes

DI-GEL Anti-flatulent, antacid ASPIRIN Pain reliever, blood thinner

9. Identify the medication that are sources of nutrients and indicate the nutrients. MOM 15 to 30% of Mg is abs. 10. Which medications could cause gastric bleeding? Briefly explain how. Aspirin Decreases platelet aggregation and increases bleeding time. Mobic Increases the risk of bleeding when taken with drugs anti-platelet drugs such as aspirin. 11. What are possible causes of Mr. Ds lack of taste? A side effect of MM is dysgeusia. Medication in general is the most common reason for individuals to experience a lack of taste. 12. Do you agree or disagree with the RDs decision not to take anthropometric measurements or recommend anergy determinations? Discuss why or why not? We disagree with the RDs decision to record anthropometric measures because a baseline must be recorded in order to monitor progress. Because Mr. D is at high nutritional risk it is imperative to collect data such as AMA and TSF due to cachexia. We know Mr. Ds ideal body weight to prescribe an optimal meal plan to promote weight and muscle gain. Usual body weight should be noted as a means to establish a baseline and determine the amount and rate of weight loss. 13. When hospitalized, Mr. D was given 50 mg of thiamin IM every day x 3 days. What is the current RDA for thiamin for a 73 YOM? How would such a dose be justified, especially since he is to receive one amp of MVI-12 every day? The RDA for a 73 YOM is 1 mg/day. Thiamin in large quantities will not become toxic because thiamin is entry dependent which can cause deficiency of other vitamins and minerals. However Mr. D is not at risk for other vitamin/mineral deficiency because he is taking a multivitamin. High doses of thiamin can improve muscle coordination and confusion. 14. Look up and record the RDAs for folic acid and mg for a 73 YOM. Discuss how you could justify such as dose of folic acid and Mg. Mr. D is also receiving M.T.E 5 (see Appendix D). Folic acid RDA is 320 mcg/day. Folic acid is administered to Mr. Ds because it helps produce healthy red blood cells therefore reducing the risk of anemia. Trace elements is not significant because folic acid is not considered a trace element. 15. Compare the RDAs for a 51 YO, a 73 YO and a 90 YO. Considering the results of these comparisons, what do you think about the sufficiency of the RDAs?

The RDA is the same requirement for 51, 73 and 90 year olds. There is no variance between the groups. We believed the RDAs are adequate for healthy 51, 73 and 90 YOs because studies have proven the RDA will prevent deficiencies. 1.0 mg/day of thiamin will prevent beriberi, Wernicke-Korsakoff syndrome, heart failure and cataracts; however exceeding the RDA will not be harmful. The RDA of 320 mcg/day of folic acid is adequate because it helps form red blood cells and produce DNA. 16. Calculate Mr. Ds basal energy expenditure using the Harris-Benedict equation. Determine a stress factor to multiple this by and determine total energy needs. 66.5 + 13. (w) + 5.0 (H) 6.8 (a) 66.5 + 13.8 (60.45) + 5.0 (182.88) 6.8 (73) 66.5 + 834.21 + 914.4 496.4 = 1,319 (1.3) = 1,714 1,700 kcals 17. Considering Mr. Ds mental and physical condition, his nutritional deficiencies, his medications and his calculated energy needs plan a 3 day sample menu for Mr. D that would meet his needs. SEE EXCEL 18. Discuss how you might influence Mr. D to eat. We can talk to Mr. D and survey him for food preferences; perhaps he did not like the food being served to him. Mr. Ds meals will be scheduled daily to maintain a consistent routine. His foods will be prepared with herbs, sauces and dressings to enhance aroma. If his appetite remains poor, an appetite stimulant (ex: dronabinol) is recommended to help stimulate his appetite and zinc supplement to improve his taste acuity. If Mr. D continues to have disordered eating patterns and PO intake below 50% he may be a candidate for tube feeding via PEG tube. 19. Comment on the dietitians chart note. Was it adequate? Were the components in the right place? Did it need additional information? The RDs note was not adequate because of the exclusion of pertinent information. For example, the note is missing the following: nutrition diagnosis, BMI, GI function, medication, dentures, calcium, ALP/TP, albumin and TLC levels. The plan in the note: will send diet as ordered with high kcal and nourishments TIB is not specific. The plan should have noted Mr. Ds food preferences as well. Nourishments should be provided to the patient if his PO intake continues to remain poor; initial nourishment should be BID to monitor tolerance of the nutritional nourishment. Mr. D is at high nutritional risk (cachexia, malnutrition), which warrants follow up should be in two days rather than three. Simply starting and monitoring a calorie count is not sufficient enough to monitor patient progress. Measurements such as weights, and GI function should be monitored as well.

Using a table below, compare several of the enteral nutritional supplements that provide about 1 kcal/ml and can be taken orally or with a feeding tube (There is room for seven comparisons)
VOL TO MEET RDA

PRODUCT

PRODUCER

FORM Kcal/ml

PRO:N

GRAMS/LITER
PRO CHO FAT

Na mg

K mg

kG WATER

FIBER/L

FREE H2O

Nutren Nutren with Fiber Promote with Fiber Promote Impact Vital 1.0 Optimental Peptamen

Nestle

L 1.0 L 1.0 L 1.0 L 1.0 L 1.0 L 1.0 L 1.0

133:1 133:1

40 40

127 127

38 38

880 880

1240 1240

370 410

1,500 1,500

0 14

1,275 1,260

Nestle Abbot

75:1

63

138

28

1,300

2,100

380

1,000

14

831

Abbot Nestle Abbot

75:1 71:1 131:1

63 56 40

130 130 130

26 28 38

1,000 960 1,055

1,980 1,600 1,400

340 375 390

1,000 1,500 1,422

0 0 4.2

839 1,275 1275

Nestle

131:1

40

127

39

560

1,500

270

1,500

1275

Using the table below, compare several of the enteral nutritional supplements that provide 1.5 kcals/ml and that can be taken orally or with a tube.
VOL TO MEET RDA

PRODUCT

PRODUCER

FORM Kcal/ml

PRO:N

GRAMS/LITER
PRO CHO FAT

Na mg

K mg

kG WATER

FIBER/L

FREE H2O

Glucerna Jevity

Abbot Abbot

L 1.5 L 1.5 L 1.5 L 1.5 L 1.5 L 1.5 L 1.5

88:1 122:1

82.5 63.8

133.1 215.7

75 49.8

1,380 1,400

2,520 2,150

875 525

1,500 1,000

16.1 22.0

741 760

Osmolite

Abbot

125:1

62.7

54.3

49.1

1,400

1,800

762

1,000

762

Vital Isosource Nutren

Abbot Nestle Nestle

139:1 116:1 131:1

67.5 67.6 60

187 168 168

6.0 64.8 68

1,500 1,300 1,160

2,000 2,140 1,880

764 778 775

1,000 1,000 1,000

6.0 8 0

764 780 760

Impact

Nestle

63:1

94

140

63.6

1,170

1,870

770

1,000

770