Mechanical problems, such as dysphagia secondary to cerebrovascular accidents or degenerative brain diseases that affect swallowing are frequently encountered in the hospitalized older patient. Also, diseases that affect appetite and feeding increase the risk for negative energy balance such as GI diseases, endocrine diseases, infections, COPD, and others.
Many drugs have been associated with weight loss, especially in frail older adults. Drugs can cause a decrease in appetite, changes in food tastes and adsorption, and increase the body’s metabolism, making the patients unable to meet their caloric needs. Drugs implicated in malnutrition and weight loss in older persons include digoxin, amiodarone, methotrexate, lithium, and amitriptyline (to name a few).
Often the patient has poor oral intake for weeks—even months—prior to hospitalization. The duration of poor intake or weight loss may affect the patient’s prognosis and treatment. The inability to meet the calories needed by mouth can be a potential marker for a serious disease. Social factors such as isolation, poverty, and lack of transportation may also play a role in poor oral intake and even weight loss. Therefore, the mechanisms of poor nutrition or weight loss have to be identified before PEG tube placement is recommended.
The Clinical Case of Mrs. H
Mrs. H is an 88-year-old, 90-pound white woman admitted to the hospital for the third time this year secondary to aspiration pneumonia. She has a significant past medical history of 20-pound weight loss in the past year and advanced Alzheimer’s disease with severe aphasia. Her functional status is poor. She has been unable to walk or feed herself for at least a year.
Situations like this often arise in the acute care setting. The practitioner may ask how much and what kind of care makes sense for someone like Mrs. H with a limited life expectancy. She has advanced dementia with possible dysphasia and aspiration pneumonia that can explain her poor oral intake. In Mrs. H’s case, other factors can cause her poor oral intake, such as medications, malignancy, delirium, and psychosocial issues.
In this case, the first goal is to identify the cause(s) of poor oral intake and weight loss for future treatment and prognosis. Target your diagnostic investigation at the most probable explanation. “Shotgun” investigations have low yields and should be avoided. In Mrs. H’s case, discontinue medications that can affect her oral intake such as anticholinergic drugs if possible.
If Mrs. H can swallow, the next step is to provide frequent, small meals with liquid oral supplements between meals (60 to 90 minutes before meals). Oral protein and energy supplements have been shown to reduce all-cause mortality in older patients.10 You might consider the use of orexigenic medications, but they usually take significant time to work and their benefit in Mrs. H’s case is questionable. If she is diagnosed as depressed, a trial with mirtazapine may help both her depression and weight loss.
Other effective strategies to promote oral intake in older adults involve eliminating dietary restrictions and allowing unlimited intake of favorite foods. However, in Mrs. H’s case, poor intake may not improve due to the acute medical problems of aspiration pneumonia and the severity of her dementia with dysphagia. Often, a short course of tube feeding through a nasogastric tube can be tried until the patient’s acute illness improves. In Mrs. H’s case though, she has received nasogastric nutrition during her two recent hospitalizations, and her clinical situation has continued to worsen.
Mrs. H’s two daughters want to discuss PEG placement to improve her nutritional status. She had a recent modified barium swallowing study that showed dysphagia with high risk for aspiration of solids and liquids.