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9 Psychiatric Aspects of Nutritional Disorders, Frailty, and Failure to Thrive
- Johns Hopkins University Press
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Nutritional disorders, frailty, and failure to thrive are highly prevalent medical conditions in long-term care populations, and their prevalence is even higher in LTC populations with psychiatric disorders (e.g., dementia, depression, or delirium) (Robertson and Montagnini 2004; P. Thomas et al. 2004; Morley et al. 2006). Fortunately, these disorders are eminently treatable . Psychiatric Aspects of Nutritional Disorders In an elderly population, healthy dietary patterns are related to decreased total mortality and lower disease-specific mortality. While poor nutrition is not a natural concomitant of aging, older adults who experience several concurrent diseases are at higher risk of undernutrition or malnutrition. Within the overall older cohort, LTC populations are more likely to consume an unbalanced diet (P. Thomas et al. 2004). Under- or malnutrition can be defined as any insufficient dietary intake of essential nutrients (macronutrients [carbohydrates, fat, protein], micronutrients [vitamins, minerals], and fluid), and it is typically multifactorial in its etiology (Morley 2001; Amella 2004). Under- or malnutrition is a common, multidimensional, frequently undetected problem for approximately two out of every five nursing home residents, negatively influencing their health and quality of life (Kayser-Jones 2000). Obesity is the result of a form of malnutrition, with a caloric intake that exceeds energy expenditures. The consequences of malnutrition can be devastating and fatal (table 9.1). C H A P T E R 9 Psychiatric Aspects of Nutritional Disorders, Frailty, and Failure to Thrive P S y C H I AT R I C A S P E C T S O F N U T R I T I O N A L D I S O R D E R S 229 Unintentional Weight Loss Unintentional weight loss is prevalent in LTC populations. A low energy intake goes together with an insufficient supply of micronutrients. Elderly people in LTC tend to have both a lower energy intake—mainly due to a lower intake of fat—and a lower protein intake. In older adults, nearly all of their higher mortality risk is due to weight loss, independent of a person’s initial body weight. Although depression is the most common cause of unintentional weight loss in LTC residents, the clinician should thoroughly evaluate residents with this problem to identify other causes (table 9.2). Weight loss may be due to dehydration. Rapid and acute weight loss in excess of 3 percent of one’s baseline body weight is most likely due to reduced total body water from dehydration. Residents with certain medical conditions (e.g., severe COPD, congestive heart failure) may be unable to consume a large meal at one sitting and may do better with multiple small meals. The clinician should use the Mini Nutritional Assessment, or MNA (www.mna -elderly.com), to assess both residents who are at risk of weight loss (have a poor appetite, feel full after eating only a small amount, report that the food tastes bad, eat one or less than one meal a day) and residents who already have weight loss, as well as to treat any reversible causes of weight loss (Vellas et al. 2006). Sarcopenia (excessive age-related muscle loss), a common cause T A B L E 9 . 1 Potential complications and consequences of malnutrition Delirium (due to hypoglycemia, dehydration, electrolyte imbalance, drug toxicity from a reduction in serum protein binding, etc.) Cognitive impairments Functional impairments Frailty Failure to thrive Acute renal failure Falls and injuries (e.g., a hip fracture, a subdural hematoma) Pressure ulcers, or decubitii A compromised immune system leading to recurrent infections (e.g., urinary tract infections, pneumonia) and poor wound healing Vitamin deficiency and its complications (e.g., dementia, peripheral neuropathy, depression) Anemia Electrolyte imbalance and its complications (e.g., seizure) Oral ulcers Sarcopenia (severe loss of muscle mass) Exacerbation of chronic medical illnesses (e.g., diabetes, chronic kidney disease, osteoporosis) Death [44.222.146.114] Project MUSE (2024-03-28 15:14 GMT) 230 P S y C H I AT R I C C O N S U L TAT I O N I N L O N G - T E R M C A R E of weight loss in LTC populations, may be due to testosterone deficiency, peripheral vascular disease, inadequate protein intake, and a lack of physical activity.The clinician should address a loss of appetite, poor positioning while eating, and oral status concerns. Table 9.3 lists various tests and measurements we recommend for screening and assessing nutritional disorders and monitoring the response to treatment. We recommend...