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Name: Amanda Tome NTD 413

Medical Nutrition Therapy: A Case Study Approach 3rd ed.


Case 5 – Polypharmacy of the Elderly: Drug-Nutrient Interactions
Instructions: Please complete each question listed below. Be thorough in answering these questions. With any calculations,
please show your work. Use any resources available to complete these questions; chapter 11 of your textbook will help you
complete this assignment. Make sure to look up any unfamiliar terms or concepts. Answers can be typed directly onto this
document and should be uploaded to D2L by February 5th at 9 pm.

I. Understanding the Disease and Pathophysiology (one point each)


1. Identify each of the medical diagnoses (reasons for admission) for Mr. Kaufman.
Mr. Kaufman was admitted to University Hospital for metabolic alkalosis and mild dehydration.

2. Identify which of these may affect cardiac function, liver function, and renal function.
Metabolic alkalosis can affect renal function because the kidneys compensate for increased alkalinity by
producing more hydrogen ions and increasing reabsorption of bicarbonate. Metabolic alkalosis can affect
cardiac function because it affects potassium levels, which regulate heart contractions. If left untreated,
severe metabolic alkalosis can lead to heart failure. Chronic dehydration can affect renal function because
fluid imbalance is regulated by the kidneys to maintain blood volume. Dehydration affects electrolyte status
and blood osmolality. A change in plasma concentration above 290mOsm signals the hypothalamus to trigger
the pituitary gland to release the antidiuretic hormone (ADH), so more water can be reabsorbed bythe
kidneys. Dehydration can also decrease blood volume, which decreases blood pressure, which in turn can
impact cardiac function.

3. Are there also normal changes in renal function that occur with aging?
Yes, changes in renal function occur as people age because the kidney nephrons decease in size and number,
causing the kidney to shrink. Kidney tubules also become less effective. Atherosclerosis, common in the
elderly, can also narrow the renal arteries decreasing kidney function. In fact, by age 80 the GFR is decreased
by approximately half compared to that of a young adult. Chronic diseases such as diabetes, which become
more likely as one ages, also affect renal function.

4. Define polypharmacy. Do you think that Mr. Kaufman’s medications represent polypharmacy? Why is
polypharmacy a concern in the elderly?
Polypharmacy is taking multiple medications concurrently. Polypharmacy is also associated with taking
multiple medications to treat the same condition, taking a medication that is not needed, using improper
dosage, taking a medication to combat another medication’s side effects, and drug-drug interactions.
There is currently no strict guideline on the number of medications, but Mr. Kaufman is taking eleven
medications, which definitely indicates polypharmacy.
Polypharmacy is a concern to elderly because they have high rates of chronic disease and usually take
multiple medications. As people age, cardiac, liver and renal functions decline and lean body mass decreases,
changing the person’s body composition. These physiological factors alter how the body absorbs,
metabolizes and excretes the medications. Lastly, the elderly are more inclined to take the medications
improperly for various reasons: forgetting to take medication, misunderstanding directions, inability to afford
medications, and inadvertently taking additional doses due to forgetting that the first dose was taken.

II. Understanding the Nutrition Therapy (two points each)


5. Describe the potential nutritional complications secondary to pharmacotherapy.
Medications can have effects on nutrient ingestion, absorption, metabolism, and excretion. Some
medications can cause GI dysfunctions like nausea, vomiting, diarrhea, constipation, can affect appetite and

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saliva production, and alter the sense of taste and smell. All of these factors can disrupt eating habits and
affect nutrient intake. Medications can alter the pH of gastric juices, increase the transit time of nutrients,
cause gastric emptying, or have side effects like nausea, vomiting, diarrhea and constipation that can affect
the absorption of certain nutrients by not providing adequate time or an appropriate metabolic environment
for absorption in the GI tract. Medications can interfere with the nutrient metabolism through various
mechanisms, such as competing for cell binding sites and increasing metabolic processes. Most medications
are excreted by the kidneys in urine, so medications that increase urination can also increase the excretion of
nutrients. Some medications also alter renal function, affecting reabsorption of the medication and nutrients.

6. Describe the potential effect of nutrition on the action of medications.


Just as medications affect nutrition, nutrition affects the action of medication by altering drug dissolution,
absorption, metabolism and excretion. Medications may require a specific stomach pH level and transit time
for it to be dissolved and absorbed. The digestion of food affects the rate of gastric emptying, as different
nutrients are digested at different rates. Food can either enhance or inhibit the absorption of some
medications. Certain nutrients can bind with a medication, altering absorption. Nutrients and medications
can compete for binding sites and transport carriers, reducing the bioavailability of the medication. Certain
nutrients can either speed up or slow down metabolic enzyme systems. When a metabolic enzyme system is
induced, it can speed up the dissolution of a medication, allowing it to move through the GI tract too quickly,
causing decreased absorption. The pH of urine, which can be affected by dietary intake, can alter the
reabsorption of a medication in the kidneys, changing the medication’s concentration in the body.

III. Nutrition Assessment


A. Evaluation of Weight/Body Composition (two points each)
7. Mr. Kaufman is 5’5” tall and weighs 196 lbs. Calculate his body mass index. How would you interpret
this value? Should any adjustments be made in the interpretation to account for his age?
BMI = [weight (lbs.) / height (in.)2] x 703 = [196 lbs. / (65 in.)2] x 703 = 32.6
Mr. Kaufman falls into the class 1 obese category.
Interpretation adjustments do not need to be made to account for his age. Mr. Kaufman is an 85-year-old
man, and as people age, lean body mass declines and body fat increases, indicating that a high BMI is
indicative of obesity. Mr. Kaufman also appears obese, which supports this conclusion.

8. Calculate Mr. Kaufman’s percent usual body weight. Interpret the significance of this assessment.
Mr. Kaufman’s daughter reports that he weighed 225 lbs. three years ago when he moved in with her but
that his weight has been stable for the past year. Mr. Kaufman’s usual body weight is reported as 195-225 lbs.
 %Weight Change = [(UBW-ABW) / UBW] x 100%
 [(195-196)/195] x 100% = 0.5% weight gain
 [(225-196)/225] x 100% = 12.9% weight loss
Mr. Kaufman’s weight change ranges from 12.9% weight loss to 0.5% weight gain. Given the family
interview and patient history, these changes are not significant. The 12.9% weight loss seems to have
occurred over a two-year time frame, which is not significant and is beneficial given his classification as
obese and his diagnosis of type 2 diabetes and hypertension. His weight has been stable for the past year with
only 0.5% (1 lb.) increase, which is not significant.

9. When completing a nutritional assessment on an older individual, should specific changes in body
composition and energy requirements be considered? If so, which changes?
Yes, body composition and energy requirements need to be considered when completing a nutritional
assessment on an elderly person. As people age, their lean body mass decreases and body fat increases. Lean
body mass is more metabolically active and requires more energy than adipose tissue. Elderly require less
energy because they are typically less active and more sedentary, and have lower metabolic demands due to
their body composition. In Mr. Kaufman’s situation, he is obese and should lose weight. After using

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evidence-based calculations to estimate energy needs, like the Mifflin-St. Jeor equation, the estimate may
need to be lowered for weight loss to occur.

B. Calculation of Nutrient Requirements (three points)


10. Calculate energy and protein requirements for Mr. Kaufman. What factors should you consider when
estimating his requirements?
Estimated Energy Needs:
ABW = 196 lbs / 2.2 kg. = 89.09 kg.
Height = 5’ 5” = 65 in. x 2.54 = 165.1 cm.
REE = [9.99 x weight (kg.)] + [6.25 x height (cm)] – (4.92 x age) + 5 = (9.99 x 89.09 kg.) + [6.25 x 165.1 cm]
– (4.92 x 85) + 5 = 1508.7 kcal x 1.2 (sedentary) = 1810.4 kcal – 250 kcal (if weight loss is warranted) = 1560
kcal – 1810 kcal
Although Mr. Kaufman is obese, I would recommend that he not be prescribed a restrictive diet to
maintain his quality of life, since he is 85 years old. Weight loss in the elderly also accelerates the decline of
lean body mass even when adipose tissue is lost. My recommendation is that Mr. Kaufman should consume
approximately 1800 calories per day; however, if he wants to lose weight in an attempt to manage his
diabetes, hypertension or coronary artery disease, I would recommend that he reduce is daily caloric intake to
1560 calories.
Mr. Kaufman’s gender, age, weight, height, BMI and level of physical activity are required in order to
estimate his calorie needs using the Mifflin-St. Jeor equation, which is the gold standard formula for
overweight and obese individuals. Mr. Kaufman’s body composition is also a factor that should be
considered. Elderly individuals lose lean body mass and gain adipose tissue as they age. Unlike lean body
mass, adipose tissue is not metabolically active, so an individual with more body fat will require less energy
than an individual with a leaner body mass. Quality of life is also an important factor to be considered when
estimating energy needs and dietary recommendations for the elderly.
Estimated Protein Needs:
There are many factors that affect protein needs. Normal, healthy adults require 0.8-1.0 g/kg of protein.
Mr. Kaufman is 85 years old and the elderly have higher protein requirements (1.0g/kg). Mr. Kaufman also
has a BMI greater than 27, increasing his protein needs to 1.5-2.0 g/kg IBW. Lastly Mr. Kaufman suffers
from renal insufficiency, which requires less protein (0.8 g/kg). Based on these factors, I recommend
calculating his protein needs as 1.0 g/kg so he can meet his body’s needs but not overburden his kidneys.
Protein needs = 1.0 g/kg body weight = 1.0 g x 89.08 kg = 89 g protein

C. Intake Domain (three points each)


11. There are several ways to estimate fluid needs. Calculate Mr. Kaufman’s fluid needs by using at least
two of these methods. From your evaluation of his usual intake, do you think he is getting enough
fluids? Is this a common problem in aging?
Method 1 (Based on energy intake): 1 mL of fluid per kcal = 1 ml x 1310 kcal (recommended) = 1310 mL
fluid
Method 2 (Based on body weight): 25 mL/kg for adults > 65 years = 25 mL x 89.08 = 2227 mL fluid. This
seems excessive and because he is obese, I recommend calculating his fluid needs based on his ideal body
weight. 25-30 mL/kg x 61.81 kg = 1545 mL - 1854 mL fluid
Mr. Kaufman’s estimated fluid intake is 44-48 oz. (1320-1440 mL) based on 3 cups of coffee, ½ cup
cranberry juice, 12-18 oz. iced tea and Jell-o. Based on Method 2’s estimate of his fluid needs, Mr. Kaufman
is not taking in enough fluids. He is also taking a diuretic, which increases fluid loss. This conclusion is
supported by his diagnosis of mild dehydration. Inadequate intake of fluids is a common problem in the
elderly because as humans age, thirst signals become blunted and the body loses water due to the decline in
lean body mass and an increase in body fat. Lean body mass contains more water than adipose tissue.
12. Evaluate Mr. Kaufman’s usual intake for both caloric and protein intake. How does it compare to
MyPlate recommendations?

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Based on Mr. Kaufman’s usual dietary intake, he is consuming approximately 1500-1700 calories and
approximately 121 g. protein per day. Based on MyPlate’s Supertracker recommendations, he should be
consuming 1800 calories and 56 g. protein per day. Current MyPlate recommendations for a man 51 years or
older is to consume 2 cups of fruit, 2½ cups of vegetables, 6 oz. of grains, ½ of which should be whole-grain,
5½ oz. of protein and 3 cups of dairy. Based on these recommendations and his usual dietary intake, Mr.
Kaufman is consuming inadequate amounts of fruits, vegetables, dairy and possibly whole-grains but excess
protein. I would recommend that Mr. Kaufman increase his fruit, vegetable and dairy consumption and
decrease his protein intake. I would also suggest that he consume whole-grain bread and pasta and brown
rice, if he is not already doing so.

D. Clinical Domain (four points each)


13. Mr. Kaufman was diagnosed with mild metabolic alkalosis and dehydration. What is metabolic
alkalosis? Read Mr. Kaufman’s history and physical. What signs and symptoms does the patient
present with that may be consistent with metabolic alkalosis and dehydration? Explain.
Metabolic alkalosis is a condition caused by the retention of bicarbonate or the loss of non-volatile acid.
Metabolic alkalosis is characterized as alkalosis with volume decrease or alkalosis without volume
contraction. Alkalosis with volume decrease involves a fluid imbalance and is caused by sustained vomiting,
use of diuretics and/or nasogastic suction. Alkalosis without volume contraction does not involve a fluid
imbalance and is caused by excessive intake of sodium bicarbonate or corticosteroids, chronic antacid use,
hyperaldosteronism, or a blood transfusion. Metabolic alkalosis can indicate a kidney issue because the
kidneys normally compensate for a loss of acid by decreasing bicarbonate reabsorption and by producing
hydrogen ions.
Metabolic alkalosis does not present with any specific signs and symptoms but those can occur due to
changes in volume balance and electrolyte status, which are accompanying conditions of metabolic alkalosis.
Mr. Kaufman is exhibiting confusion, which is a symptom of dehydration. Mr. Kaufman also presents with a
soft systolic murmur, and heart rhythm changes can occur from hypokalemia, which is associated with
metabolic alkalosis. Mr. Kaufman presents with dry membranes in his mouth, which also is associated with
dehydration, as the body is preserving fluid for vital functioning.

14. What laboratory values support his medical history of renal insufficiency? What laboratory value(s)
support this diagnosis of metabolic alkalosis? Which are consistent with dehydration? What laboratory
values support his medical history of type 2 diabetes mellitus? Use the table below to indicate the
various diseases/conditions.

Laboratory Normal Mr. Kaufman’s Value Disease/Condition Which May


Cause Abnormality
Albumin 3.5–5 g/dL 3.4 (mild depletion) Renal insufficiency
Potassium 3.5–5.5 mEq/L 3.4 (mild depletion) Medications
Osmolality 285–295 mmol/kg/H2O 310 (elevated) Dehydration
Glucose 70–110 mg/dL 172 (high elevation) Type 2 Diabetes
BUN 8–18 mg/dL 32 (high elevation) Renal insufficiency, dehydration
and type 2 Diabetes
Creatinine 0.6–1.2 mg/dL 1.5 (elevated) Renal insufficiency and
dehydration
HbA1c 3.9–5.2% 8.2 (high elevation) Type 2 Diabetes
pH 7.35–7.45 7.47 (mild elevation) Metabolic alkalosis
pCO2 35–45 mm Hg 46 (mild elevation) Metabolic alkalosis
CO2 23–30 mmol/L 30 (high normal) Normal
HCO3 24–28 mEq/L 32 (elevated) Metabolic alkalosis

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15. Using the following table, list all the medications that Mr. Kaufman was taking at home. Identify the
function of each medication and any potential drug-drug or drug-nutrient interactions.

Medication Function Drug–Drug Interaction Drug–Nutrient


Interaction
Diovan  Antihypertensive  Potassium-sparing diuretics, None
(Valsartan)  Congestive heart failure treatment potassium supplements or salt
 Type 2 Diabetes nephropathy treatment substitutes
 Left ventricular dysfunction treatment  NSAIDs
 Lithium
 Insulin
Prilosec  Anti-ulcer  Warfarin  St. John’s
(omeprazole)  Anti-GERD  Diazepam Wort
 Anti-secretory  Antiretroviral agents  Gingko
 Methotrexate
 Tacrolimus
 Drugs with pH-dependent absorption
 Zocor
Neurontin  Anti-epileptic Morphine None
 Post-herpetic neuralgia treatment
 Mood stabilizer
 Neuropathy treatment
 Hot flashes treatment
 Migraine treatment

Furosemide  Diuretic  Aspirin Natural licorice


(Lasix)  Antihypertensive  Lithium
 Carafate
 NSAIDs
 NPH & regular insulin
Isosorbide  Anti-angina  Phosphodiesterase-5-inhibitors None
mononitrate  Vasodilator  Other Vasodilators
 Anti-hypertensives
 Tizanidine
 Ergot Alkaloids
 Ace Inhibitors
 Neuroleptic agents
 Psychotherapeutic agents including
Trazadone
 Iloprost
 MAOIs
 Prilosec
Sodium  Antacid  Aspirin None
bicarbonate  Alkalinizing agent  Iron sulfate or ferrous sulfate
 Mineral supplement  Tacrolimus (Prograf)
 Alprazolam (Xanax)

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Medication Function Drug–Drug Interaction Drug–Nutrient
Interaction
Aspirin  Analgesic,  NSAIDs Avoid or limit:
 Anti-pyretic,  Methotrexate  Garlic
 Anti-arthritic,  SSRIs  Ginger
 NSAID,  Anticoagulants  Gingko
 CVA or MI prevention  Anti-hypertensives, diuretics &  Ginseng
 Platelet aggregation inhibitor ACE inhibitors, including Diovan  Horse
 NPH & regular insulin chestnut
 Sodium bicarbonate

Multivitamin Vitamin supplement If it includes iron: None


 Thyroid
 Certain antibiotics
 Antacids
 Levodopa
 Bisphosphonates
NPH and Anti-diabetic & Hypoglycemic treatment  Diovan None
regular  Aspirin
insulin  Furosemide
 Albuterol
 Clonidine
 Reserpine
 Beta-blockers

Trazodone  Anti-depressant  Digoxin  St. John’s


 Heterocyclic  MAOIs Wort Gingko
 Insomnia treatment  Azole antifungals  Ginseng
 Aggression & panic attack treatment  HIV protease inhibitors  Valerian
 Macrolide antibiotics
 Rifamycins
 Anti-seizure medicines
Zocor  Anti-hyperlipidemic  Strong CYP3A4 Inhibitors,  St. John’s
(Simvastin)  Cardiovascular event prevention Cyclosporine, or Danazol Wort
 Lipid-Lowering Drugs That Can  Grapefruit
Cause Myopathy When Given Alone
 Amiodarone, Dronedarone,
Ranolazine, or Calcium Channel
Blockers
 Niacin
 Digoxin
 Coumarin Anticoagulants
 Colchicine

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