POLYPHARMACY OF THE ELDERLY: DRUG-NUTRIENT INTERACTIONS Adapted

POLYPHARMACY OF THE ELDERLY: DRUG-NUTRIENT INTERACTIONS Adapted from Medical Nutrition Therapy – A Case Study Approach – Marcia Nahikian Nelms Bob Kaufman, an 85-year-old Caucasian male, has been brought to the hospital emergency room because of a change in his mental status. Mr. Kaufman suffers from several chronic diseases that are currently treated with multiple medications. Sudden onset of confusion over past 24 hours. Lives with daughter for 3 years, daughter cooks all meals except breakfast. Mr. Kaufman is responsible for his own medicine, does his own insulin injections and monitors his blood glucose. Still drives and does volunteer work. Height: 5’8″ Weight: 190 pounds Blood pressure: 160/82 Personal Articles: Eyeglasses, Dentures (upper & lower) Education: High school, 1 year of college Occupation: Retired postal clerk Social History: Lives with daughter (age 45), son-in-law (age 52) and 2 grandsons (ages 11 and 16) Past Medical History (PMHx): CAD, Type 2 DM, renal insufficiency, peripheral neuropathy, osteoarthritis, Hx of prostate CA, diverticulitis/diverticulosis, hypertension Meds: Vasotec, Prilosec, Neurontin, furosemide, isosorbide mononitrate, trazodone, sodium bicarbonate, aspirin, multivitamin, Zocor, NPH and regular insulin Nutrition History: Patient’s daughter states that patient’s appetite is good – “probably too good!” Daughter prepares most meals. Dad snacks between meals, but daughter states that she tries to have low-sugar and low-fat choices available. He weighed almost 235 pounds when he came to live with her and her family almost 3 years ago. His weight has been stable for the past year. Her biggest concern nutritionally is that her father never seems to drink fluids except at mealtime, and she is worried that he doesn’t get enough. “I will pour him a glass of water between meals. He will take one sip, and then he just lets it sit there.” She states that she tries to keep his calories down and limits simple sugars. That is about as far as they go with diabetic restrictions. She states, “I just don’t feel my father will eat anything more restrictive. I figure at 85, we’ll just do the best we can.” Usual dietary intake: Am eggbeaters – 12 oz carton scrambled with 1 tbsp shredded cheese, 2 slices bacon, 1 slice toast, 1⁄2 cup cranberry juice, 3 c coffee with fat-free creamer. About twice a week, he has corn flakes with a banana and 2% milk for breakfast. Lunch Dinner Snacks usually from the Senior Center – diabetic lunch – 2 to 3 oz meat, 1 to 2 vegetables 1⁄2 c each, roll, 1⁄2 c fruit, 6 to 8 oz iced tea 3 to 4 oz meat, rice, potato, or noodle 1 c, 1 slice of bread, 1⁄2 c fresh fruit, 6 to 8 oz iced tea usually 2 to 3 times daily: sugar-free jello, low-fat yogurt, microwave popcorn Diet Prescription (Rx): 1,800 kcal CHO Counting Previous Nutrition Therapy – Yes, when first diagnosed with DM over 15 years ago Hospital Course: Diagnosis – Metabolic alkalosis secondary to excessive intake of sodium bicarbonate; mild dehydration. Patient is receiving NS 40mEq of KCL @75cc/hr for 24 hours. As electrolyte abnormalities resolve, confusion will resolve as well. Patient stated that he was confused with medications. Nutrition consults prior to discharge. Lab Patient’s Value Normal Value Albumin 3.0 3.5-5.0 Sodium 149 136-145 Potassium 2.8. 3.5-5.5 Glucose 172. 70-110 BUN 32 8-18 Creatinine 1.5 0.6-1.2 Chol 175 120-199 HDL 41 >45 LDL 135 <130 TG 175 40-160 HbA1C 8.2 3.9-5.2 Osmolality 310 285-295 pH 7.47 7.35-7.45 pCO2 46 35-45 HCO3 32 24-28 Hgb 10 14-18 Hct 38%. 42-52% MCV 77 80-95 Mr. Kaufman's diagnosis is metabolic alkalosis due to excessive intake of sodium bicarbonate. The patient's metabolic alkalosis may progress due to: Renal insufficiency Increase in stomach acid Prolonged vomiting Diabetes 2. Mr. Kaufman was also diagnosed with mild dehydration. Which lab value reflects this? BUN Osmolality Glucose All of the above What two medications are contributing to the patient's dehydration and low serum potassium? Zocor and Aspirin Sodium Bicarbonate and furosemide Vasotec and Prilosec Neurontin and Trazodone Which of the following are potential complications secondary to pharmacotherapy? Nausea/vomiting Diarrhea/constipation Altered saliva production/perceived taste All of the above Nutrition has the potential to affect dissolution of medications. Which of the following conditions could affect dissolution? Altered urinary pH Interaction with vitamin C Presence of fat (food) in the stomach Consuming alcohol with the medication With metabolic alkalosis and mild dehydration, there is a decrease in potassium levels which can negatively affect: Liver function Cardiac function Respiratory function All of the above Mr. Kaufman is 85 years old, what normal changes in renal function occur with aging? A decrease in glomerular filtration rate A decrease in the ability to conserve sodium A decrease in the ability to concentrate urine All of the above 8. What is Mr. Kaufman's BMI? 28.9 31.6 32.8 34.2 What is Mr. Kaufman's percent UBW? 81% 87% 115% 124% Given Mr. Kaufman's weight loss, what is the nutritional significance of this? Severe weight loss, high nutritional risk since it is >10% Not significant since it was lost over a two-year period Not significant since he is obese and needs to lose weight Moderate risk because the elderly shouldn’t lose weight Since Mr. Kaufman is 85 years old, what is one of the major factors in determining his energy requirements? Physical activity Hormonal changes Muscle Chronic disease Using the Mifflin-St. Jeor equation, without subtracting for weight loss, with an activity factor of 1.2 what are Mr. Kaufman’s daily energy requirements? 1400-1500 kcal 1600-1700 kcal 1500-1600 kcal 1700-1800 kcal 13. Calculate Mr. Kaufman’s daily fluid requirements based on 25-30 mL/kg of body weight. 1700-1800 mL per day 2150-2580 mL per day 2225-2670 mL per day 2550-3060 mL per day What laboratory values support Mr. Kaufman’s diagnosis of Type 2 DM? BUN and creatinine Glucose and Hgb A1c Potassium and phosphorus Sodium and potassium From the information gathered within the intake domain; list Mr. Kaufman’s possible nutrition problems using diagnostic terms. Inadequate oral beverage intake Excessive protein intake Inadequate mineral intake (K+) All of the above Prilosec is a proton pump inhibitor used in the treatment of GERD. It may decrease the absorption of: Iron Calcium which also decreases bone density Vitamin B12 by preventing separation from dietary protein All of the above Which of the following foods would you recommend that a patient increase when taking Furosemide? Meat, chicken or fish Milk and cheese Banana, orange, potato, and tomatoes None of the above Besides causing metabolic alkalosis, sodium bicarbonate may: Decrease the absorption of iron Cause gastric bleeding Decrease magnesium Cause hypoglycemia Zocor should not be taken with: Milk Tea Orange juice Coffee A nutrition problem in the behavioral-environmental domain that Mr. Kaufman has is food and nutrition-related knowledge deficit. What is the etiology of this? Food and nutrition-related knowledge deficit related to ______________ Undesirable food choices Less than desired intake of fruits and vegetables Food medication interactions Lack of desire to drink fluids The signs and symptoms to compete the above PES statement is as evidenced by __________ Inadequate consumption of potassium and excessive intake of sodium Not following previous nutrition recommendations Typical intake of minerals at 25% of recommended daily average intake 1.3 liters of fluid intake daily compared to recommended intake of 2 liters Complete this PES statement – Excessive protein intake related to approximately 6-8 ounces of meats including eggs as evidenced by Meeting less than 50% of needs Typical daily intake of 90 grams of protein compared to recommended average daily intake of 70-80 grams Undesirable food choices All of the above Mr. Kaufman takes a multivitamin. Do you think that he needs it? No, he is obese and consumes excessive calories Yes, the recommendations for Ca+, Vitamin D and fluoride are increased with aging, and he does not consume adequate vegetables or dairy products No, he suffers from polypharmacy and does not need to take additional supplements Yes, he should take it because he is 85 years old Write nutrition assessment in ADIME format. Make sure to include in your intervention an appropriate diet order for the patient. SCIENCE HEALTH SCIENCE NURSING DFN 348

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