Case Study 1: Malnutrition and Depression

Case Presentation

ML is a 75 year old widow who was brought to her primary care physicians office by the local Older
Americans Transportation Service (doesnt drive herself). She had missed her two prior scheduled office
visits because of the recent death of her husband and a subsequent fall, which resulted in an
intertrochanteric fracture of her right hip.

On presentation, ML appeared withdrawn and much more frail than on previous visits. She answered in a
monotone with terse, nonspontaneous speech, and she lacked expression. When asked about how she has
been coping after the loss of her husband, she became tearful. She admitted that in addition to the loss of
companionship, the loss of his pension has caused tremendous financial hardship.

Past Medical History

ML tripped on the steps in her house 2 months ago and fractured her hip. She underwent an open
reduction/internal fixation surgery to repair the fracture, and the operation went well. She had no serious
operative complications, but she lost approximately 250cc blood during the procedure (1 unit = 500cc).
ML underwent inpatient rehabilitation for 10 days after discharge from the surgical service and then
returned home, where she lives alone. She ambulates slowing with a cane and can climb stairs only with
difficulty.

During her inpatient rehabilitation stay, she was diagnosed with depression and she was started on an
antidepressant. She has no major chronic diseases except for osteoporosis, discovered at the time of her
hip fractures 2 months ago. ML had an appendectomy at age 46 and bilateral cataract surgeries 10 years
ago. She has no previous history of pneumonia, tuberculosis, hepatitis, or urinary tract infection.

Medications
ML currently taking fluoxetine (Prozac), 20mg daily, for depression and an iron supplement for anemia
three times per day. She also self-medicates with over the counter preparations of ibuprofen (200-400mg
three times a day) and frequently uses over th counter laxatives and glycerin suppositories for her
constipation, which she attributes to her iron tablets. She does not take a multiple vitamin, calcium or
vitamin D. She has no known food allergies.

Social History

ML lives alone in the four-bedroom, two-story home she has occupied since she married 55 years ago.
Her son and daughter both live out of state. Although they call her every few weeks, they have not visited
since her husbands death. ML also explains that she used to attend church and visit the local senior
center regularly with her husband but has not been to see her lately. ML explains that she has no energy to
get up and go anymore and she falls asleep in front of the television. She also reports being constipated
and that her food does not have much taste. She avoids alcohol and tobacco and drinks one cup of coffee
and two cups of tea daily.

Review of Systems

General: Weakness, fatigue, weight loss, and depression.

Mouth: Food lacks taste (hypoguesia); dry, thick-feeling tongue; sores in corners of mouth.
Gastrointestinal (GI): Poor appetite, constipation.
Extremities: Hip pain when climbing stairs, some tenderness at old incision site, and chronic low back
pain

Physical Examination

Vital Signs

Temperature: 97.0 deg F

Heart rate: 88 BPM
Respiration: 18 BPM
Blood pressure: 130/80 mm Hg
Height: 56
Current weight: 110 lb
Usual weight: 140lb
BMI: 18

General: Thin, elderly woman who is appropriately conversant but withdrawn. She is well groomed, but
her clothes are loose fitting, suggesting weight loss.
Skin: Warm to touch, patches of dryness and flaking to elbows and lower extremities
Head, ears, eyes, nose, throat (HEENT): Temporal muscle wasting, no enlargement of thyroid
Mouth: Ill-fitting dentures, sore beneath bottom plate, cracks/fissures at corners of mouth (angular
cheilosis)
Cardiac: Regular rate at 88 BPM
Abdomen: Well-healed appendectomy site scar, no enlargement of liver or spleen, diffusely diminished
bowel sounds
Extremities: Well-healed hip surgery incision with slight surrounding erythema (reddening), no sores on
feet, trace pretibial edema to both lower extremities
Rectal: Hard stool in vault, stool test for occult blood negative
Neurologic: Alert, good memory, no evidence of sensory loss
Gait: Slightly wide-based with decreased arm swing, antalgic and tentative but with safe, appropriate use
of cane

Laboratory Data

Albumin: 2.5 g/dL (normal 3.5-5.8g/dL)

Hemoglobin: 11.0 g/dL (normal 11.8-15.5 g/dL)
Hematocrit 33.0% (normal 36-46%)

MLs 24 hour dietary recall:

At her physicians request, ML provided the following 24 hour recall, stating that this represent her usual
daily intake:

Breakfast (home)

1 Jelly donut
1 slice white toast
2 tbsp Jelly
1 cup coffee
Lunch (home)

2 butter cookies
1 cup chicken and rice soup
6 saltine crackers
2 cups tea

Dinner (home)
1 slice white bread
2 tbsp jelly
2 tbsp peanut putter
2 butter cookies

Total kcals: 1270

Protein: 25 gm/day (8% of kcals)- needs about 46 grams/day for women over age 70
Fat: 42 gm (30% of kcals)
Carbohydrate: 201 gm (63% of kcals)
Calcium 153mg (needs to be taking in way more- approx. 1,000 mg/day)
Iron 6 mg (should be taking in at least 5 mg- good)
Hardly drinking any fluid- needs about 2.7 L/day of total water= approx. 91 oz/day
Took in about 32 ounces of fluid on her 24 recall

Case Study 1 Questions

1. What medical, environmental, and social factors could lead to nutritional problems in this patient?
Pt doesnt drive herself, and gets transported by a local Older American Transportation Service. ML
is a recent widow, causing her to miss scheduled office visits. Recently been diagnosed with
depression, and the loss of pension of her husband has caused tremendous financial hardship. Pt lives
alone in a two story house with difficulty using stairs. Both her son and daughter live out of state
with little contact. Tripped on the steps in her house 2 months ago and fractured her right hip. No
major chronic diseases, except for osteoporosis. Usually went to senior center and church often, but
does not have the energy to go anymore. Reports constipation and food does not have much taste.
She has ill fitting dentures, sore beneath bottom plate, and cracks/fissures at corners of mouth.
2. What do MLs BMI and percent weight change indicate about her nutritional status?

MLs BMI is 18, which is underweight. ML has lost 30 pounds and her % wt change is -21.4%,
which indicates a severe weight loss. ML is malnourished and is at a moderate nutritional risk.

3. What nutrition-related issues do her lab values indicate?

ML has a low albumin levels, indicating malnutrition. The low hemoglobin and hematocrit levels
indicate low iron status.
4. Calculations:
 a. BEE (using Mifflin St Jeor)
(9.99 x kg) + (6.25 x cm) (4.92 x age) 161 x AF x IF
(9.99 x 50) + (6.25 x 167.64) (4.92 x 75) 161 x 1.3
(499.5 + 1,047.75 369 161) x 1.3
=1,017 kcal/day (without AF)
=1,322 kcal/day (with AF)
b. Total energy needs for repletion (weight gain)
1,322 kcal/day + 500 = 1,822 for a 1 pound gain per week
c. Protein needs
50kg x 1.0 = 50g protein/day (1.0 used to increase protein needs)
d. Fluid needs
1ml/kcal= 1,322 mL of fluid/day
e. Ideal body weight
(6 x 5) + 100= 130lb (117-143)
f. Percent ideal body weight
110/130= 84.6%
g. Percent usual body weight
110/140= 78.6% - moderate malnutrition
5. What general conclusions can you draw regarding the adequacy of her current diet?

MLs diet is nutritionally inadequate. Based on her 24 hour recall, she is consuming an inadequate
amount of protein, calcium, and fluids. She is consuming the correct amount of fat, iron, and
carbohydrate, but the types of fat are mainly saturated fat. ML is choosing food options that are easy
to make, and this may be due to the recent death of her husband, or ill-fitting dentures.

6. How can MLs diet be improved to meet her increased requirements, achieve weight gain, and relieve
her constipation? (suggest alternatives to foods she is currently consuming)

ML consumed no fruits and vegetables in her 24-hour recall, which could cause a deficiency in
multiple nutrients. Increasing fruits and vegetables could increase fiber intake, which could help
relieve her constipation. In addition, the only protein she consumed was peanut butter and chicken
and rice soup, so increasing protein could help with weight gain and reduce muscle wasting. To help
 achieve weight gain, she needs to increase her calorie consumption, and she can do this by starting on
an oral supplement or eating more calorie dense foods. Her fat intake was adequate, but the types of
fat were not healthy fat and contained mainly saturated fat. Cookies and donuts are good to have in
the diet, but more in moderation. Instead of eating these for every meal, maybe limit to once a day.
In addition, instead of white bread, replace it with whole wheat bread. Instead of a donut for
breakfast, try oatmeal or a vanilla yogurt parfait with strawberries and granola to increase her dairy
intake and receive more calcium. Overall, ML should also add in a glass of water at each meal at
least.

7. What specific recommendations would you offer to improve MLs nutritional status? Expand beyond
the diet recommendations you provided in #6.

I would educate ML on a general healthy diet. She may not know what foods contain more fiber,
calcium, etc., so getting her to understand what each foods contain would be a good start. In addition,
adding more water to her diet could for sure help her with her constipation problems and reduce the
amount of times she needs to take laxatives. I would recommend her to a dentist to fix her dentures
because this may be a main reason she is only consuming soft foods and not protein. Since she still
may not have the appetite to eat, I would recommend her starting a multivitamin to ensure she is
getting essential nutrients. Lastly, I would recommend ML possibly being put into an independent
living. It appears she gets no social interaction in her home, and going to a more structured facility
could help with her depression and provide her with more structured meals. She also has a hard time
getting around her house with stairs, so it may help to move her to a one bedroom apartment in an
independent living home.

ADIME note:
Assessment: Pt is a 75 y/o female admitted due to her recent hip fracture. Anthropometrics: Ht:
56, 66, 167.64cm Wt: 110lb, 50kg UBW: 140lb IBW: 130lb (117-143) %UBW: 78.6% -
moderate malnutrition %IBW: 84.6% BMI: 18- underweight wt loss of 30 lb. % wt loss: 21.4%
Labs: Albumin- 2.5 g/dL (normal 3.5-5.8g/dL), Hemoglobin: 11.0 g/dL (normal 11.8-15.5
g/dL), Hematocrit 33.0% (normal 36-46%) Meds: Fluoxetine (Prozac), 20mg daily, for
depression and an iron supplement for anemia tid. Frequently uses over the counter laxatives and
glycerin suppositories for her constipation. Allergies: NKA. Client Hx: Pt doesnt drive herself,
and gets transported by a local Older American Transportation Service. ML is a recent widow,
causing her to miss scheduled office visits. Recently been diagnosed with depression, and the
loss of pension of her husband has caused tremendous financial hardship. Pt lives alone in a two
story house with difficulty using stairs. Both her son and daughter live out of state with little
contact. Tripped on the steps in her house 2 months ago and fractured her right hip. No major
chronic diseases, except for osteoporosis. Reports constipation and food does not have much
taste. Underwent an open reduction/internal fixation surgery to repair hip fracture. Diet history:
MLs diet is nutritionally inadequate. Based on her 24-hour recall, she is consuming an
inadequate amount of protein, calcium, and fluids. She is consuming the correct amount of fat,
iron, and carbohydrate, but the types of fat are mainly saturated fat. ML is choosing food options
that are easy to make, and this may be due to the recent death of her husband, or ill-fitting
dentures. Energy Needs: Kcal: 1,322 kcal/day (Mifflin x 1.3 AF) Protein: 50g protein/day
(1.0/kg) Fluids: 1,322 mL of fluid/day (1mL/kcal) NFPE: Pt appears frail, weak, and depressed.
Has temporal muscle wasting, ill-fitting dentures, sores in mouth, and cracks/fissures at corners of
mouth (angular cheilosis). Pt reports constipation, lack of taste in food, and hip pain when
climbing stairs in house. Pt is at a moderate nutritional risk.
Diagnosis: Inadequate energy intake related to poor appetite and depression due to recent loss of
husband as evidenced by a wt loss of 30 pounds and a % wt change of -21.4%.
Intervention: Nutrition px: Kcal: 1,322 kcal/day, Protein: 50g protein/day, Fluids: 1,322 mL of
fluid/day. Initiate an increased energy diet of 1,822kcal/day for a wt gain of 1lb per week.
Initiate multivitamin. Recommend Boost bid to increase calorie and protein intake. Educate on a
general healthy diet.
Monitor/Evaluate: Check weight at following check up to monitor wt gain. At next check up,
conduct another 24 hour recall to observe any changes in diet and test labs of albumin,
hematocrit, and hemoglobin again. Monitor consumption of oral supplement.
Sarah Brand
11/7/17
15:54