DRUG-NUTRIENT INTERACTIONS
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 egg beaters – 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 consult prior to discharge.
Lab Patient’s Value Albumin 3.0
Sodium 149
Potassium 2.8
Glucose 172 BUN 32 Creatinine 1.5 Chol 175 HDL 41 LDL 135 TG 175 HbA1C 8.2 Osmolality 310 pH 7.47 pCO2 46
Normal Value 3.5-5.0 136-145 3.5-5.5 70-110
8-18 0.6-1.2 120-199 >45
<130 40-160 3.9-5.2 285-295 7.35-7.45 35-45
HCO3 32 Hgb 10 Hct 38% MCV 77
24-28 14-18 42-52% 80-95
1.
2.
3.
4.
5.
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
Mr. Kaufman was also diagnosed with mild dehydration. Which lab value reflects this? a. BUN
b. Osmolality
c. Glucose
d. 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
Neurotin 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. b. c. d.
What a. b. c. d.
What a. b. c. d.
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
is Mr. Kaufman’s BMI? 28.9
31.6 32.8 34.2
is Mr. Kaufman’s percent UBW? 81%
87% 115% 124%
Given Mr. Kaufman’s weight loss, what is the nutritional significance of this? a. Severe weight loss, high nutritional risk since it is >10%
b. Not significant since it was lost over a two-year period
c. Not significant since he is obese and needs to lose weight
d. 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?
a. Physical activity
b. Hormonal changes c. Muscle
d. 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 c. 1500-1600 kcal
1600-1700 kcal d. 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
14. What
a. BUN and creatinine
19. Zocor
a. Milk
laboratory values support Mr. Kaufman’s diagnosis of Type 2 DM?
Glucose and Hgb A1c
Potassium and phosphorus
Sodium and potassium
15. From
nutrition problems using diagnostic terms.
the information gathered within the intake domain, list Mr. Kaufman’s possible
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
should not be taken with:
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.
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