Usually 6 months of rifampicin and isoniazid, with pyrazinamide (and ethambutol) for the \201 rst 2 months only Ethambutol may be omitted if the risk of resistance to isoniazid is low \200 Longer treat ment periods may be needed for extrapulmonary disease In older people: Drug resistance is rare, as most infections are recurrences of primary disease, contracted decades ago Failures of treatment are usually due to poor concordance. Combination drug preparations may improve this (eg Rifater = rifampicin + isoniazid + py razinamide) Side effects are more common, including ocular toxicity from ethambutol (reduce dose in renal impairment) and hepatitis from isoniazid. Close monitoring is important Atypical mycobacteria, eg Mycobacterium avium intracellulare or kansasii can occur in those with structural lung disease such as bronchiectasis. This requires even broader and more p rolonged courses of antibiotics but isolation is not required as it does not spread from pe rson to person This page intentionally left blank 342 CHAPTER 11 Chest medicine Asthma and COPD: assessment Presentation Asthma and COPD (Table 11.3 ) in older people: \200 Are both diseases characterized by air \202 ow obstruction \200 Commonly coexist, eg in the childhood asthmatic who has smoked \200 May both be mimicked by other common di seases eg cancer, pulmonary embolism, heart failure May present late: older people are less aware of hypoxaemia, breathlessness or bronchoconstriction Are underdiagnosed and undertreated, especially in older people Asthma \200 May present i n old age as true \200\230late onset asthma \200\231. There are also increasing numbers of people who have grown old with their asthma \200 In older people, c ough may dominate, symptoms \202 uctuate less, triggers (eg cold, smoke, allergens) are l ess frequent and the association with hay fever or eczema is less strong Nocturnal cough or dyspnoea, including paroxysmal nocturnal dyspnoea, may be caused by asthma NSAIDs and B -blockers (oral or ocular) may worsen bronchoconstriction COPD \200 Is much more common in older age, the consequence of intrinsic ageing and progressive disease Is caused by environmental exposure, usually to tobacco smoke, in genetically susceptible people. Signi \201 cant disease can develop in those who have not smoked for years, as acquired lung damage depends more on \200\230total pack years \200 \231 smoked rather than duration alone Symptoms are usually more chronic and slowly progressive, without signi \201 cant variability If bronchitis is signi \201 cant, there is a productive cough (most days of at least 3 mon ths of 2 consecutive years). Fatigue and sleep disturbance are common. Daytime somnolence s uggests ventilatory failure \200 There may be associated anemia of chronic disease, osteo porosis, malnutrition, and depression Investigations \200 Oximetry will determine the presence and degree of hypoxaemia. In moderately or severely hypoxaemic patients (O 2 saturation <92 % ), consider ABGs to det ermine whether long-term oxygen therapy may be of bene \201 t ( see b \200\230Oxygen ther apy \200\231, p.348) and, in the acutely unwell, to guide oxygen administration CXR , ECG , and FBC will help to exclude other pathology, eg anemia, dysrhythmia ASTHMA AND COPD: ASSESSMENT 343 PEFR , measured regularly (bd \200\224 qds) for up to 2 weeks, helps determine whether var iable airways obstruction (asthma) exists. Variability (cid:116) 20 % is signi \201 cant. Older people may \201 nd using PEFR meters and charting the results dif \201 cult. Ask t hem to demonstrate technique, reading the device, and charting in clinic Spirometry . Obtain at least FEV 1 and forced vital capacity (FVC). An FEV 1 : FVC ratio of <70 % suggests obstruction \200 Older people often have dif \201 cu lty performing pulmonary function tests; an experienced technician in a respiratory laboratory will help provide accurate res ults Assessments for bronchodilator responsiveness using inhaled bronchodilators are now considered less helpful, as they are poorly predictive of the respo nse to treatment, and do not distinguish reliably between asthma and COPD. However, air \202 ow obstruction that completely and repeatedly resolves after bronchodilator administra tion does exclude COPD Assessments for steroid responsiveness can be helpful in distinguishing between asthma and COPD (response is greater in asthma than COPD, although t here is overlap). Perform spirometry before and after steroids (either 2 weeks of prednisol one 30mg od, or 6 weeks of inhaled beclometasone 400micrograms bd) \200 Some patients sho w improvement in FVC or functional status (walking distance or speed) despite no signi \201 cant change in FEV 1 Table 11.3 Distinguishing Asthma from COPD Asthma COPD Modest degree of \201 xed airways obstruction (this is uncommon in younger people) Greater degree of airways obstruction Signi \201 cant or full reversibility No, or only minimal, reversibility (cid:116) 20 % variability in PEFR <20 % variability in PEFR Greater age Signi \201 cant smoking history 344 CHAPTER 11 Chest medicine Asthma and COPD: drug treatment In general, treatment principles are similar to those in yo unger people, and are described in detail in British Thoracic Society guidelines. However s ome differences and some similarities bene \201 t from emphasis. Bronchodilators \200 Older people perceive symptoms less reliably, so where there is evidence of variable airways obstruction, give bronchodilators regularly rather than as req uired In older age, response to anticholinergics, eg ipratropium, tiotropium, may be better than to B -agonists, eg salbutamol High dose B -agonists, eg from nebulizers, may cause tremor, tachycardia or rate-related an gina. Nebulizers may not be required \200\224 try higher inhaled doses via a spacer (eg sa lbutamol 400 \200\223800micrograms (4 \200\2238 puffs of a standard metered dose inhaler)), or long-acting B -agonists, eg salmeterol Anticholinergic bronchodilators uncommonly cause side effects such as dry mouth or blurred vision, more often with higher (nebulized) doses and with long-acting preparations. Acute g laucoma is a rare but important complication \200\224 reduce ocular exposure by nebulizing via a mouthpiece rather than a face mask Corticosteroids \200 Long-term oral steroids are rarely bene \201 cial \200 In those r eceiving regular courses of oral steroids for acute exacerbations, give osteoporosis prophylactic treatment. Inhaled steroids alone probably do not cause osteoporosis Theophylline \200 Toxicity is common in older people. Plasma levels are increased by febr ile illness, heart failure and drugs, eg erythromycin/cipro \202 oxacin. Serious side effe cts, eg convulsions may be the \201 rst sign of toxicity \200 Check levels when titrati ng dose. Most of the therapeutic effect is seen by the lower end of the therapeutic range, so target this \201 rst Before introducing oral theophylline, optimize inhaled bronchodilator and steroid therapy, including the use of long-acting and higher dose preparations if necessary Other \200 In \202 uenza and pneumococcal vaccine should be given \200 Exercise extrem e caution in the use of respiratory depressants , eg benzodiazepines or opiates. In general: \200 In acutely unwell patients with CO 2 rete ntion, stop them, reintroducing only if withdrawal effects occur In stable patients with or without CO 2 retention, withdraw or reduce them where possible In severe, end-stage COPD, if dyspnoea or cough are distressing and cannot be otherwise rel ieved, consider giving opiates. Give small doses initially, but increase as needed to relie ve distress, even if respiratory function deteriorates. Explain the rationale to staff, rel atives and the patient if appropriate ASTHMA AND COPD: DRUG TREATMENT 345 HOW TO Improve drug delivery in asthma or COPD \200 The traditional metered dose in haler alone is rarely adequate, due to dif \201 culties in coordinating device activation and the onset of inhalation Adding a large volume spacer device reduces the need to coordinate activation with inhalation, improving drug delivery and reducing side effects (eg oral thru sh). Spacers are generally better tolerated by older patients who don \200\231t tend to con sider them such a social handicap as youngsters Breath-activated devices provide an alternative to the metered dose inhaler, although lung volumes may not be adequate to activate the device. They vary widely in design, and patient s vary greatly in ability to use them Assess and advise on technique regularly, involving both hospital and community teams (doctor, nurse, and pharmacist) as well as the family and other carers Nebulizers are rarely required. A metered dose inhaler via a large volume spacer device is usually just as effective. Patients in whom nebulized drugs are being considered should be referred for specialist assessment Where concordance is an issue, eg in a person with dementia living alone \200 Give long-acting preparations where possible, eg salmeterol in place of salbutamol, tiotropium in place of ipratropium \200 Give combined preparations e g Combivent in place of salbutamol and ipratropium Once daily inhaled steroid is better than none \200 Supervise taking of medication as oft en as possible, but accept that taking for pulmonary drugs, taking medications irregularly is probably better than tak ing them not at all Rarely, inhaled drugs are administered too frequently by cognitively impaired people. This very rarely causes side effects, but relatives may need reassurance that this is the case Occasionally, oral B -agonists are useful, in patients in whom all inhaled preparations have been unsuccessful Further reading British Thoracic Society guidelines online: M www.brit-thoracic.org.uk . 346 CHAPTER 11 Chest medicine Asthma and COPD: non-drug treatment \200 Smoking cessation should be advised, except in t he very advanced or terminal phase, where it may lack bene \201 t and be unkind. Consider referring for support and/or nicotine replacement therapy Exercise is bene \201 cial, sometimes available as part of a pulmonary rehabilitation sche me. Elements should include aerobic and strength-based exercises as well as speci \201 c b reathing exercises \200 Pulmonary rehabilitation is as effective as inhaler therapy, and should be a key part of treatment. It is a complex intervention tailored to the individual, with e xercise, behavioral and educational components. Individual action plans can be followed by older people, facilitating self-management and early intervention Weight reduction is bene \201 cial in the obese. However weight commonly falls in advanced disease as the work of breathing exceeds calori \201 c intake, and nutritional supplement s may be needed Comorbidities including depression are common and should be treated aggressively Social and practical interventions . A comprehensive multidisciplinary assessment may be wa rranted. Provide appropriate mobility aids, eg electric wheelchairs, stairlifts, and alarm systems, eg pendant alarms. Treat social isolation Assisted ventilation \200 Consider this in cases of respiratory arrest, respiratory acido sis, delirium, exhaustion or deteriorating respiratory function despite full treatment. Hypercap nia rather than hypoxaemia is usually the key contributor to delirium; sedation is likely t o worsen ventilation and precipitate coma For some patients with acute-on-chronic deterioration, ventilation will be futile and inapp ropriate. Make such a decision after considering: \200 The nature of the chronic illness and recent deterioration \200 The presence of reversible factors \200 The patient \200 \231s current physiological status \200 The views of the patient or others who represent them \200 If in doubt, request guidance from the ITU team Non-invasive ventilation (NIV), eg nasal intermittent positive pressure ventilation provide s an acceptable alternative to invasive ventilation (usually endotracheal intubation). NIV is often well tolerated, can be delivered on specialist or high-dependency wards, and provi des a modest level of ventilatory support that can be weaned promptly as the patient recove rs Palliative interventions \200 Reassure \200\224 many patients are frequently terri \201 ed. Assure them that their symptoms of suffocation can, and will be treated. Consider adva nce care planning Positioning \200\224 sit up, day and night \200 Involve the palliative care team. Their advice and support is often valuable and can continue into the community if discharge occur s This page intentionally left blank 348 CHAPTER 11 Chest medicine Oxygen therapy \200 Oxygen is a drug \200\224 it has clear indications, and common and i mportant side effects Precision and care in prescribing maximizes bene \201 t and reduces harm \200 In older p eople, dyspnoea may be more frequently accepted, leading to underprescribing However, indiscriminate prescribing, particularly the use of high- concentration oxygen, risks respiratory depression, and CO 2 narcosis. This is common in ol der people with COPD Long-term oxygen therapy (LTOT) This improves prognosis in severe COPD and in moderate COPD with fea- tures of cor pulmonale. To reduce pulmonary hypertension, arterial pO 2 should b e raised above 8kPa for at least 15hr each day. Concentrations of inspired oxygen (FiO 2 ) of 24 \200\22328 % usually achieve this. Respiratory depres- sion is very rarely a problem in patients with stable respiratory failure who receive low oxygen concentrations. Speci \201 c criteria must be met before prescribing LTOT. Measure arterial blood gasses t wice, on air, at least 3 weeks apart, and at least 4 weeks after an acute exacerbation. Cri teria include: P a O 2 7.3 \200\2238.0kPa in COPD with complications such as peripheral oedema, evidence o f pulmonary hypertension, or polycythaemia \200 P a O 2 <7.3kPa in COPD without the compl ications already listed Intermittent oxygen therapy (IOT) This is useful for a variety of c ardiorespiratory conditions, eg COPD, advanced heart failure, lung cancer. It relieves dist ress and improves exer- cise tolerance and mobility. Low concentrations (24 \200\22328 % ) can achieve signi \201 cant symptomatic bene \201 t. Prognosis is unaltered. High concentration oxygen therapy Oxygen at 40 \200\22360 % is useful for short-term use in respiratory failure without hypoventilation and CO 2 retention , commonly seen in acute he art failure, PE, and pneumonia. Even in these cases, high- \202 ow oxygen may reduce respi ratory drive, leading to CO 2 narcosis. This is especially common in older people, those wi th a smoking history, the acutely unwell and where respiratory depressants (eg opiates, ben zodiazepines) are co-administered. Avoid this by: Keeping saturations just below normal (90 \200\22394 % ) rather than normal or above normal (98 \200\223100 % ) Avoiding respiratory depressants \200 Monitoring closely for signs of CO 2 retention OXYGEN THERAPY 349 Oxygen delivery systems Supply patients with an administration device applicable to their c ircum- stances. Latest guidelines for hospital are that clinicians should prescribe the tar get saturation range and state whether controlled/constant per- formance is required and th at nurses should monitor the patient and determine the most suitable delivery system within those parameters. Constant performance oxygen delivery systems (eg Ventimask 28 % ) provide a stable FiO 2 (2 4 % , 28 % , 32 % , etc.) for a range of ventilation rates. 28 % is suitable for most patie nts receiving LTOT. These must always be used for hypoventilating patients with elevated P a CO 2 . Variable performance oxygen delivery systems . FiO 2 varies. The system delivers oxygen at a given rate which mixes with room air at rates dependent on ventilation. Systems include \200 Nasal cannulae. Often better tolerated by patients, and allow them to eat and talk. W ith oxygen \202 ows of 1 \200\2232L/min, FiO 2 is usually low (less than 28 % ), but can approach 30 % if the patient hypoventilates \200 Simple face mask, eg Hudson. Provides va riable FiO 2 up to 40 % \200 Non-rebreathing mask with reservoir bag. Provides variable F iO 2 up to 60 % Oxygen gas supply Oxygen concentrators are costly to purchase but running costs are low. Th ey are cost-effective when needing low \202 ow oxygen for prolonged periods ( (cid:116) 8 hr per day). Oxygen is piped to convenient position(s) in the home, and usually administere d via nasal cannulae. Urgent installations can usually be arranged within 24hr. Oxygen bott les are useful for: Patients on LTOT via an oxygen concentrator who wish to leave their home for short periods Patients needing oxygen as required, who do not meet the LTOT criteria Patients who are likely to have a short-term need for continuous oxygen, eg for end-of-life palliation, for whom installation of an oxygen concentrator may not be worthwhile A small oxygen cylinder ( \200\230PD oxygen cylinder \200\231; 300L, lasting 2hr) is availa ble which is convenient for wheelchair excursions, or travel in a car. 2Smokers should stop smoking before beginning oxygen therapy. The risk of burns and household \201 res is sub stantially increased. 350 CHAPTER 11 Chest medicine Asbestos-related disease The period between asbestos exposure and overt (or covert) disease is usually long, often over 20 years. Almost all new cases are in older people because asb estos exposure is so carefully regulated now. The exposure may not be clearly recollected b y the patient but always consider in high- risk occupations including builders, dock work a nd heavy engineering. Con \201 rming the diagnosis is important because compensation may b e due if disease can con \201 dently be shown to have arisen as a consequence of asbestos exposure. If the diagnosis could not be con \201 rmed during life, then post-mortem con \201 rmation may lead to compensation payments to relatives. Pleural plaques Discrete areas of thickening of the pleura that often calcify. Benign. A ma rker of asbestos exposure, but of no further clinical signi \201 cance. However, compensat ion is payable for this alone, if the claim is made promptly following diagnosis. Asbestosis Progressive \201 brosis, clinically and radiographically similar to idiopathic pul- monary \201 brosis. Usually due to prolonged and substantial occupational exposure. Mesothelioma A malignant, incurable tumor of the pleura, presenting as cough, chest pain, e ffusion, or dyspnoea. Very poor prognosis; few survive over 2 years. Treatment is nearly al ways palliative; the tumor is not resectable, and is relatively insensitive to chemotherapy or radiotherapy. Asbestos expo- sure may have been only transient. Bronchial carcinoma There appears to be a synergistic effect between asbestos and tobacco. 351 Chapter 12 Gastroenterology The ageing gastrointestinal system 352 The elderly mouth 354 Nutrition 356 HOW TO Manage weight loss in older patients 357 Enteral feeding 358 HOW TO Insert a \201 ne-bore NG feeding tube 359 The ethics of clinically assisted feeding 360 Oesophageal disease 362 Dysphagia 364 Peptic ulcer disease 366 HOW TO Investigate and manage persistent unexplained nausea and vomiting 367 The live r and gallbladder 368 HOW TO Approach an older patient with abnormal liver function tests 369 Constipation 370 Diverticular disease 372 HOW TO Image the older colon 373 In \202 ammatory bowel disease 374 Diarrhea in older patients 376 HOW TO Investigate and manage chronic diarrhea 377 Other colonic conditions 378 The \200\230acute surgical abdomen \200\231 380 Obstructed bo wel in older patients 381 Obesity in older people 382 352 CHAPTER 12 Gastroenterology The ageing gastrointestinal system Teeth \200 Change color \200\224 yellow and less tran slucent \200 Become worn (enamel does not regenerate) \200 Decreased vascularity and se nsitivity of dentine and pulp \200 Caries, periodontitis, and tooth loss are common but n ot inevitable in older patients. Being \200\230long in the tooth \200\231 refers to gum re traction seen with periodontal disease which increases with poor oral hygiene and xerostomi a, both common in older people Mouth \200 Mucosa \200\224 thinner and more friable, rarely a functional problem \200 Salivary glands do not produce less saliva but causes of xerostomia (see b \200\230Xerosto mia \200\231, p.355) are more frequent with increasing age \200 Bone resorption occurs in the mandible alongside osteoporosis. This is accelerated with periodontitis and progresses fast once teeth are lost leading to a change in facial appearance Orofacial muscle tone can also diminish with consequent dribbling Taste Olfactory function, and hence taste discrimination, decreases gradually with normal a geing but an acute change or complete absence of taste should prompt investigations for a c ranial tumor. Esophagus \200 Slight changes in innervation produce clinically insigni \201 cant change s in swallow and peristalsis The misnamed presbyoesophagus (see b \200\230Oesophageal motility disorders \200\231, p.363) is a disorder of oesophageal motility, not a universal age chang e Hiatus hernias and re \202 ux are very common \200\224 probably related to anatomical and postural changes Stomach \200 Increased incidence of atrophic gastritis (with reduced acid production) but in the absence of disease most older patients maintain normal pH levels Reduction in gastric emptying is common \200 Increased mucosal susceptibility to damage \200 Increased Helicobacter pylori carriage but this is less likely to cause ulceration Small intestine \200 Function well preserved except for calcium absorption which is decreased Increased incidence of bacterial overgrowth with malnutrition and diarrhea THE AGEING GASTROINTESTINAL SYSTEM 353 Large intestine Decreased rectal sensation contributes to high incidence of constipation. Pancreas Structural changes including atrophy but function is well-preserved. Liver \200 Hepatic weight and volume decrease by around 25 % and there is brown (lipofuscin) pigment build-up, but liver function (and therefore LFTs) is not affecte d Some older patients have a slightly low bilirubin and albumin level but results still remain within the normal range Gallbladder \200 Incidence of gallstones increases (40 % females > 80), probably related to reduced rate of synthesis and excretion of bile Most gallstones are asymptomatic 354 CHAPTER 12 Gastroenterology The elderly mouth Mouth examination Use gloves. Be systematic. Important and often not done \200\224 serious pathology may be missed. Check: \200 Parotid glands (enlarged in parot itis, alcoholism, chronic lymphoid leukemia) Temporomandibular joint (arthritis causes crepitus, subluxation, pain). Dislocation can cause pain and inability to close mouth Soft tissues : tongue and \202 oor of mouth commonest site for oral cancer in smokers/alcoholics. Angular stomatitis Salivation : ( see b \200\230Xerostomia \200\231, p.355) \200 Teeth : how many missing, how many restorations, pain/sensitivities Caries is increased by poor brushing and low \202 uoride exposure, diet of soft sweet foo ds, xerostomia, poor \201 tting dentures, and infrequent dentist visits Dentures : cleanliness, integrity, and \201 t General management \200 Nursing help with dental/mouthcare is vital for anyone unable to help themselves Referral to a dentist. Dental check-ups should continue every 6 months regardless of age/di sability. This is very dif \201 cult to arrange for inpatients but maxillofacial surgeons (who are also trained as dentists) will sometimes help out in severe/urgent cases Consider chlorhexidine mouthwash for patients with poor oral self- care, eg stroke, dementia Severe periodontal disease may require antibiotics (topical or systemic) and surgical debridement to arrest progress Poor oral and dental health contributes to poor appetite and malnutrition \200\224 consider nutritional support (see b \200\230Nutrition \200\231, p.3 56) Facial pain Consider trigeminal neuralgia, temporal arteritis, parotitis, temporoman- dibul ar joint arthritis, dental caries/abscess, aphthous mouth ulcers, or the idiopathic benign \200\230burning mouth syndrome \200\231. Sore tongue Can be a side effect of drugs, glossitis (B12, iron, or folate de \201 ciency) , candida/thrush especially after antibiotics or in diabetes. A black tongue may be due to Aspergillus colonization and is treated with nystatin loz- enges/mouth rinse. Parotitis Acute bacterial parotitis is not uncommon in frail older patients who are not eat ing. Low salivary \202 ow (dehydration and not eating) and poor oral hygiene predispose t o parotid gland infection with mouth \202 ora (staphylococci and anaerobes). Treat with a ggressive rehydration, iv \202 ucloxacillin and chlorhexidine mouth rinses. Response to t reatment is usually dramatic \200\224 if not consider abscess formation or MRSA. THE ELDERLY MOUTH 355 Xerostomia Perception of dry mouth is closely related to salivary \202 ow. Saliva is need ed for: \200 Taste : dissolves food to present to taste buds \200 Swallow : helps form food bolus \200 Protection of teeth and mucosa: contains antibacterials, buffers and mucin. Rapid tooth decay is a risk of xerostomia Xerostomia is not a normal ageing change and should always be investi- gated. Causes includ e: \200 Drugs with anticholinergic side effects (eg tricyclic antidepressants, levodopa) Sj gren \200\231s syndrome (an autoimmune destruction of salivary glands) can be primary or associated with other autoimmune conditions \200 Irradiation, salivary ston es, tumors, sialadenitis (viral or bacterial infections) Treatment depends on cause \200\224 stop or decrease causative drugs, stimu- late saliva w ith grapefruit juice/sugar-free sweets or mints, and promote frequent careful mouthcare. Ar ti \201 cial saliva can provide symptomatic relief for some patients. Oral candidiasis May manifest as oral thrush (with removable white plaques on ery- thematou s base), angular stomatitis (sore cracks in corner of mouth), or, rarely atrophic forms (eg under dentures, may not have creamy plaque). Consider and reverse risk factors such as ant ibiotics, steroids, hypergly- caemia, and immunosuppression, where possible. Use nystatin 1 mL qds rinsed around mouth for several minutes. In cases with painful swallowing/ dysphagia (ie might have oesophageal involvement) and those that cannot comply with rinses use oral \202 uconazole 50 \200\223100mg od for 7 \200\22314 days. Dentures should be kept out whe re possible and soaked in chlorhexidine during treatment. Mouth ulcers Simple aphthous ulcers and ulcers due to poorly \201 tting dentures should b e treated with topical anti-in \202 ammatories (salicylate gel or triamci- nolone), hydroc ortisone lozenges, or steroids. Ulcers can occur as part of a systemic disease such as in \202 ammatory bowel disease. Any oral lesion persisting more than 3 weeks merits referral a nd/or biopsy to exclude cancer but most mouth cancers are painless. Oral manifestation of systemic diseases/drugs A very long list including common and general (eg oral candidiasis in immu- nosuppression) as well as rare and speci \201 c (eg oral li chen planus) manifes- tations. Remember that many drugs also affect the mouth, eg xerostomi a (see b \200\230Xerostomia \200\231, p.355), tardive dyskinesia with antipsychotics, gum hypertrophy with phenytoin. Systemic manifestation of dental diseases Poor oral hygiene with dental or periodontal dise ase can cause septicaemia or infective endocarditis. Poor teeth can contribute to poor nutr ition. 356 CHAPTER 12 Gastroenterology Nutrition With normal ageing there are: \200 Reduced calorie requirements due to reduced activity and lower resting metabolic rate (decreased muscle mass) Reductions in appetite (anorexia of ageing) \200 Lower reserves of macro and micronutrien ts (vitamins and minerals) In the presence of disease older patients quickly become malnour ished, which is a powerful predictor of outcome (increased functional depend- ency, morbidi ty, mortality, and use of healthcare resources). Malnutrition is extremely common in the elderly frail or institutionalized population, and studies have shown that once in hospital most patients \200\231 nutritional status actually declines further. Protein-energy undernutrition affects: \200 15 % of community-dwelling older patients \200 5 \200\22312 % of housebound patients with multiple chronic problems \200 35 \200\22365 % of patients acutely admitted to hospital \200 25 \200\22360 % of institutionalized older persons Nutritional assessment \200 BMI (weight in kg/(height in m) 2 ) is often impractical as h eight cannot be accurately measured in immobile patients or those with abnormal posture (al though approximations can be made, eg using ulnar length) Simple weight is still useful especially if the patient knows their usual weight \200\224 rapid weight loss ( > 4kg in 6 months) is always worrying even in obese pa tients. Mid-arm circumference can be used to approximate \200 Nutrition screening tools a re often employed by nursing staff to target interventions. The MUST score (see b Appendix, \200\230Malnutrition universal screening to ol (MUST) \200\231, p.695) is widely used in UK hospitals and is sensitive for detection of protein-energy undernutrition in hospitalized patients More complex tools (eg Mini Nutritional Assessment) are helpful but time-consuming and rarely used outside research Biochemical measures (eg hypoalbuminaemia, anemia, hypocholesterolaemia) develop at a late stage and are confounded by acute illness Nutritional support \200 Identi \201 cation is key to allow targeted intervention (impro ves outcome) \200 The cause is usually multifactorial and a multidisciplinary approach is needed eg medical (immobile, unwell, re \202 ux, constipation, etc.), social (poverty, iso lation), psychological (depression, dementia) and age related (altered hunger recognition) Involve a dietician early (especially if anorexia is prominent) \200 Record food intake c arefully \200\224 this highlights de \201 ciencies in intake and helps identify where interventions might help Make mealtimes a priority (protected meal times) and provide assistance with feeding (dietetic assistants or family) Schemes such as using a red tray can highlight those in need of assistance NUTRITION 357 Establish food preferences and offer tempting, high-calorie foods (eg substitute full fat milk and yogurt if they are on the lower fat variety) Prescribe dietary supplements according to patient preference (eg milky or fruit drinks, so ups, puddings, or high-calorie shots) \200 Appetite stimulants, eg prednisolone can incre ase weight but side effects usually outweigh bene \201 ts \200 Consider the role of enteral feeding HOW TO Manage weight loss in older patients Peak body mass is reached at age 40 \200\22350 and weight loss can occur after this due to decreased lean mass, although the proportion of fat is rela- tively increased so overall we ight is often remarkably stable. As a rule of thumb unintentional weight loss of more than 5lb (2.3kg)/5 % of body weight in a month or 10lb (4.5kg)/10 % body weight in 6 months is worrying. Always try to get recorded weight (rather than relying on patient/ carer memory) \200\224 a search of old outpatient clinic and primary care records can help. Record weight regularl y while you investigate to look for ongoing trends. Dramatic weight loss should always prompt a search for remediable pathology. The cause is o ften multifactorial. It is important to consider: \200 Dementia \200 Depression \200 Malignancy \200 Chronic infection/disease, eg COPD, heart failure, TB \200 In \202 amm atory conditions, eg giant cell arteritis \200 Malabsorption (see b \200\230Diarrhea in older patients \200\231, p.376) \200 Mesenteric ischaemia (recurrent postprandial abdomin al pain) \200 Drug causes, eg digoxin, theophyllines, cholinesterase inhibitors \200 Me tabolic disorders, eg hyperthyroidism, uraemia \200 Swallowing problems \200 Persistent nausea or abdominal pain/re \202 ux \200 Social causes, eg inability to cook, poverty, social isolation, alcoholism A careful history (including dietary history and mental state with col- lateral history where possible), examination, and routine screening tests (see b \200\230Investigations \200\231, p.66) will usually give clues of signi \201 cant under- lying pathology. If preliminary investigations are negative a \200\230watch and re-weigh a nd wait \200\231 plan is reasonable \200\224 be reassured if weight is actually stable or rising, re-examine and re-screen if further loss occurs. Obviously if a remediable cause is found and treated then weight loss may be halted or reve rsed. Where no such cause is found, or where it is not reversible, interventions are still possible. 358 CHAPTER 12 Gastroenterology Enteral feeding Consider enteral feeding early if there is dysphagia (eg stroke, motor neur on disease, Parkinson \200\231s disease) or failure of oral feeding (eg severe anorexia syn dromes, intensive care unit) with an intact gastrointestinal tract. There are three common methods: Fine-bore NG tubes : simple, quick, and inexpensive. The preferred method for short-term fe eding. Some patients (usually confused/ drowsy) repeatedly pull out NG tubes. Interference with the tube increases the risk of aspiration. Persistence, supervision and careful taping can sometimes help but often a PEG or RIG is required (also described here). There is incr easing experience using NG tubes which are held in place via a nasal loop (Bridle \204 ). Trained practitioners can insert these by the bedside and removal by the patient is very r are \200 PEG : the risks of insertion include perforation, bleeding, and infection for a patient who is usually already frail. The patient has to be \201 t to undergo sedation. P roblems obtaining consent from a competent patient and \200\230agreement \200\231 from nex t of kin for an incompetent one are not uncommon. Once established, this method is discreet and better tolerated than NG tubes and is the method of choice for medium/long- term enter al feeding RIG : useful if gastroscopy technically dif \201 cult (eg pharyngeal pouch) and sometimes if small-bowel feeding preferred over gastric feeding. Similar complication rate to PEG Complications for all methods include \200 Aspiration pneumonia : there is a common misco nception that enteral feeding eliminates aspiration in dysphagic patients. This is not true \200\224 re \202 ux of food into esophagus is common and this along with salivary secretions and covert oral i ntake may still be aspirated. Always check the position of the tube if patient becomes unwe ll, feverish, or breathless. If aspiration is ongoing despite correct tube position slow th e feed, feed with patient sitting upright (ie not at night) and add pro- motility drugs, eg metoclopramide 10mg tds or erythromycin 250mg tds (pre-meals). A nasojejunal tube or jejun al extension to a PEG tube can also reduce aspiration rates (see b \200\230Aspiration pneu monia/ pneumonitis \200\231, p.332) Re-feeding syndrome : occurs when patient has been malnourished for a long time. When feedi ng commences, insulin levels cause minerals (especially phosphorus) to move rapidly into in tracellular space and \202 uid retention occurs causing hypophosphataemia, hypomagnesaemi a, and hypokalaemia. This in turn can cause life-threatening heart failure, respiratory fai lure, arrhythmias, seizures, and coma. Avoid by \200\230starting low and going slow \200 \231 when introducing feed. It is important to check and correct any abnormal biochemistry before feeding starts and then monitor frequently (check U + E, Ca, Mg, phosphate, and gluc ose daily for a few days, then weekly). Supplementation of minerals may be done intravenous ly or by adding extra to NG feed Fluid overload and heart failure : decrease volume and add diuretics \200 Diarrhea : excl ude infection (especially Clostridium dif \201 cile ). Try slowing the feed rate or changi ng the feed to one containing more or less \201 bre ENTERAL FEEDING 359 Parenteral feeding Should be considered when the gut is not functioning. It requires central venous access and should only be undertaken when supervised by an experienced nutrition team. It is usually a temporary measure, eg post- gastrointestinal surgery. Complications such as \202 uid ov erload, electro- lyte disturbance, and iv catheter sepsis are common in older patients. HOW TO Insert a \201 ne-bore NG feeding tube This task is often performed by nursing staff who may be very experi- enced. Doctors are of ten asked to help when insertion is proving dif \201 cult. 1. Get the patients consent \200\224 if they refuse come back later. They may well have just had several uncomfortable failed attempts. It is rarely appropriate to perform against the wishes of the patient 2. Have the patient sitting upright with chin tucked forward (patients often hyperextend th eir neck which makes it harder). Draw the curtains (this can be an unpleasant procedure to have done or to watch) 3. Leave the guide wire in the tube and lubricate with lots of jelly 4. Feed the tube down one nostril about 20cm (until it hits the back of the throat) 5. If there is a proximal obstruction try the other nostril 6. If possible ask the patient to swallow and advance the wire 7. Check the back of the throat carefully \200\224 you sho uld be able to see a single wire going vertically down. Start again if there is a loop 8. Secure the tube yourse lf immediately with tape to both nose and cheek Once you believe the tube is in place you need to check it is in the stomach by one or both of the following methods BEFORE you use the tube. \200 Aspiration of gastric contents th at are clearly acidic (pH <5) \200 Chest X-ray is used if there is no aspirate, or the pH is equivocal. If you leave the guide wire in, the tube shows more easily. The tip of the t ube should be clearly below the diaphragm The method of blowing air down the tube and listening for bubbles has now been discredited as a bubbling sound can be generated due to saliva and pulmonary secretions. 360 CHAPTER 12 Gastroenterology The ethics of clinically assisted feeding Feeding is a highly emotive issue. It is seen by many (especially relatives) as a basic need and hence failing to provide adequate nutrition is seen as a form of neglect or even euthanasia. In contrast, others (often nurses) feel t hat arti \201 cial enteral feeding is a cruel and futile treatment performed on incompeten t patients that only postpones a \200\230natural \200\231 death that involves anorexia or dysphagia. The use of the term \200\230clinically assisted nutrition and hydration \200\231 has been suggested by the General Medical Council (UK) to replace the term \200\230arti \201 cial nutrition and hydration \200\231 underlining the fact that this is a form of treatment.