• May 2, 2007, Antidepressant drugs: Update to the existing black box warning on the prescribing information on all antidepressant medications to include warnings about the increased risks of suicidal thinking and behavior in young adults ages 18 to 24 years old during the first one to two months of treatment.

1. Complete blood count (CBC) (including total lymphocyte count)
2. Complete metabolic panel
3. Thyroid-stimulating hormone (TSH)
4. Liver enzymes including alkaline phosphatase and bilirubin
5. Lactate dehydrogenase level
6. Serum albumin
7. Serum transferrin
8. Serum prealbumin
9. Serum cholesterol
10. 24-hour urinary creatinine/height ratio
11. Chest X-ray (CXR)
12. Screening for insufficient food intake (Mini-Nutritional Assessment at www.mna elderly.com) (Guigoz, Vellas, & Garry, 1994) (Strength of Recommendation: B; Quality of Evidence: Fair)
13. Screening for depression if indicated (Geriatric Depression Scale) (Yesavage et al., 1983) (Strength of Recommendation: A; Quality of Evidence: Good)
14. Screening for dementia if indicated (Mini-Mental Status Examination) (Folstein, Folstein, & McHugh, 1975) (Strength of Recommendation: A; Quality of Evidence: Good)

Management/Treatment

Non-Pharmacological Therapy

1. To restore a deficit, an increase up to a 100% of the recommended daily allowance (RDA) values in energy, protein, and micronutrients is required. (Strength of Recommendation: B; Quality of Evidence: Fair)
2. To restore a deficit, caloric requirements should be 30 to 35 cal/kg/day. (Just to maintain their weight and activity, the elderly need 25% greater than the standard RDA calories.) (Strength of Recommendation: B; Quality of Evidence: Fair)
3. To restore a deficit, the protein intake should be 1.5 to 2 g/kg/day. (Strength of Recommendation: B; Quality of Evidence: Fair)
4. After addressing the energy and protein requirements, the second goal is to provide the appropriate nutrient mix. Typically this consists of 50-60% carbohydrate, 25% fat and 25% protein. (Strength of Recommendation: B; Quality of Evidence: Fair)
5. Excess carbohydrates should be avoided as this may lead to hyperglycemia. (Strength of Recommendation: B; Quality of Evidence: Fair)
6. Take multivitamin supplementation to keep up with the increased metabolism and restore deficiencies. (Strength of Recommendation: B; Quality of Evidence: Good) The micronutrients (water and fat soluble vitamins and trace minerals) may need to be increased to a dose of 5 to 10 times the RDA. (Strength of Recommendation: B; Quality of Evidence: Fair)
7. The elderly also require increased calcium and vitamin D to prevent osteoporosis, along with Vitamin B and folic acid to counteract increased homocysteine and its cardiovascular effects. (Strength of Recommendation: B; Quality of Evidence: Fair)
8. Adequate hydration is required to facilitate the transport of nutrients, remove by-products and maintain cardiovascular stability. The recommendations are:
   1. 30 to 35 mL per kg body weight with a minimum or 1500 mL/day
   2. 1 to 1.5 mL per calorie consumed
   3. Replacement of added losses from disease or medications. (Strength of Recommendation: B; Quality of Evidence: Fair)

9. In an acute catabolic insult, nutritional support should be initiated within 48 hours. (Strength of Recommendation: B; Quality of Evidence: Fair)
10. Ensure adequate oral health. Poor oral hygiene, ill-fitting dentures, and dry mouth are risk factors for decreased oral intake through altered taste sensation and difficulty in chewing and swallowing. (Strength of Recommendation: A; Quality of Evidence: Good)
11. Include patients and families in the decisions about the extra food, protein, and supplements so that, with their own ideas and input, they may be more likely to comply with the treatment plan. Involvement in menu revision and food selection are also important. (Strength of Recommendation: B; Quality of Evidence: Fair)
12. Provide favorite foods and snacks. Consider food preferences, consistency, and temperature along with ethnic food choices. (Strength of Recommendation: B; Quality of Evidence: Fair)
13. Optimize energy intake with high energy foods at the best meal of the day. (Strength of Recommendation: B; Quality of Evidence: Fair)
14. Eat smaller meals more often. (Strength of Recommendation: B; Quality of Evidence: Fair)
15. Provide finger foods that are nutritious and easy to eat. (Strength of Recommendation: B; Quality of Evidence: Fair)
16. Use flavor enhancers which increase the taste of the food, therefore, augmenting intake of food by counteracting the age-related increase in smell and taste thresholds. (Strength of Recommendation: B; Quality of Evidence: Good)
17. Add fats or oils to usual foods to increase weight gain through increased energy intake which may also help to avoid satiety-related limitations which can decrease energy intake. (Strength of Recommendation: A; Quality of Evidence: Good)
18. Avoid gas-producing foods which may lead to gastric distention with air and early satiety and, therefore, decreasing the total amount of food intake. (Strength of Recommendation: I; Quality of Evidence: Poor)
19. Minimize dietary restrictions. Salt and fat contributes to the taste in food, and a regular diet does not significantly affect glucose control. Both adjustments to the diet may make meals more delectable and savory and, therefore, increase overall food intake. (Strength of Recommendation: B; Quality of Evidence: Fair)
20. Enhance the dietary environment. Use innovative dining room interventions. Make meal times interesting which are anticipated with pleasure. (Strength of Recommendation: B; Quality of Evidence: Fair)
21. Women eat more with men present. (Strength of Recommendation: B; Quality of Evidence: Fair)
22. Both men and women eat more with family present. (Strength of Recommendation: B; Quality of Evidence: Fair)
23. Eat in the company of others which leads to enhanced enjoyment of food and increased energy intake. 44% more food is eaten when eating in groups. (Strength of Recommendation: B; Quality of Evidence: Fair)
24. Larger meals are eaten on the weekends and later in the day. (Strength of Recommendation: B; Quality of Evidence: Fair)
25. More food is eaten if the meals-on-wheels delivery person stays while the recipient eats. (Strength of Recommendation: A; Quality of Evidence: Good)
26. Many older adults need assistance with their meals because of functional, physical, or cognitive disabilities. (Strength of Recommendation: B; Quality of Evidence: Fair)
27. Increasing nutrition through food should be the first step, prior to initiating dietary supplements. (Strength of Recommendation: B; Quality of Evidence: Fair)
28. If the patient's caloric needs cannot be met with 3 meals and 3 snacks per day, high energy and nutritionally dense supplements should be added. (Strength of Recommendation: B; Quality of Evidence: Fair/Poor)
29. Oral nutritional supplementation is associated with weight gain and reduced fatality. (Strength of Recommendation: A; Quality of Evidence: Good)
30. Protein/calorie supplements should be given between meals and not with meals to minimize appetite suppression and compensatory decreased intake of food at meal time. (Strength of Recommendation: A; Quality of Evidence: Good)
31. Have the patients sample the supplements and give them a variety. Presentation of the supplement should also be varied. (Strength of Recommendation: B; Quality of Evidence: Fair/Poor)
32. A liquid supplement in which the energy is supplied by glucose instead of fat is less likely to cause satiation. (Strength of Recommendation: B; Quality of Evidence: Fair)
33. Use community nutritional support services to decrease the functional limitations related to supply, preparation, and consumption of good quality food. (Strength of Recommendation: A; Quality of Evidence: Good)
34. Participate in regular exercise which promotes muscle hypertrophy, gain in lean-body mass, and may stimulate appetite. (Strength of Recommendation: C; Quality of Evidence: Poor) The evidence of the research was unable to document increased overall weight gain but did document gain in lean body mass which makes regular exercise an important adjunct in the guideline.

Pharmacological Therapy

1. Drugs should not be used as first line intervention in the elderly as there has been inadequate testing in this population. Benefits are restricted to small weight gains without indication of decreased morbidity or mortality or improved quality of life or functional ability. (Strength of Recommendation: B; Quality of Evidence: Fair).
2. Megestrol (Megace) is a synthetic progestational agent that is associated with weight gain. It may be effective in the elderly population at 800mg daily for three months. Persons receiving megestrol acetate should be monitored for adrenocortical insufficiency. (Strength of Recommendation: B; Quality of Evidence: Fair) Should not be used with bedfast patients related to DVT risk.
3. Tetrahydrocannabinol (Dronabinol – Marinol) has not been adequately tested in underweight elderly men and women but has shown some potential benefits. Dronabinol could be used when weight loss occurs without an apparent cause, and when no reversible cause is present, but is associated with central nervous system toxicity. Dronabinol appears to be a good drug for end-of-life and palliative care because it stimulates appetite, has antinausea properties, decreases pain, and enhances general well-being. (Strength of Recommendation: B; Quality of Evidence: Fair)
4. Patients receiving Megace and Dronabinol usually gain weight, but the weight is primarily adipose tissue as opposed to lean body mass. (Strength of Recommendation: B; Quality of Evidence: Fair)
5. Consider use of exogenous anabolic hormones to increase net protein synthesis. Oxandrolone (Oxandrin) is the only oral anabolic steroid that is safe and effective for weight loss and PEM (protein energy malnutrition). Studies have not shown that they lead to weight gain (Strength of Recommendation: C; Quality of Evidence: Fair)
6. Mirtazapine (Remeron) used for the treatment of depression has also been shown to increase appetite and weight gain. (Strength of Recommendation: B; Quality of Evidence: Fair)
7. The short term use of human growth hormone (Somatotropin) may be promising in severely cachetic nursing home residents, but may be associated with increased mortality. (Strength of Recommendation: C; Quality of Evidence: Fair)

Definitions:

Rating Scheme for the Strength of the Recommendations

• A – Strong recommendation that clinicians provide the service to eligible patients. There is good evidence that the service improves important health outcomes and concludes that benefits substantially outweigh harms.
• B – Recommendation that clinicians provide the service to eligible patients. There is at least fair evidence that the service can improve health outcomes but concludes that the benefits outweigh harms.
• C – No recommendation for or against routine provision of the service. There is at least fair evidence that the service can improve health outcomes but concludes that the balance of benefits and harms is too close to justify a general recommendation.
• D – Recommendation against routinely providing the service to asymptomatic patients. There is at least fair evidence that the service is ineffective or that harms outweigh benefits.
• I – Conclusion that the evidence is insufficient to recommend for or against routinely providing the service. Evidence that the service is effective is lacking, of poor quality, or conflicting and the balance of benefits and harms cannot be determined.

Adapted from: United States Department of Health and Human Services (U.S. DHHS), Office of Public Health & Science. U.S. Preventive Services Task Force. Guideline to Clinical Preventive Services, (3^rd ed.: Periodic Updates, 2000-2003), Alexandria, VA: International Medical Publishing, Inc.

Quality/Levels of Evidence

Rating Scheme for the Strength of the Recommendations

Quality/Levels of Evidence

• Good: Evidence includes consistent results from well-designed, well-conducted studies in representative populations that directly assess effects on health outcomes.
• Fair: Evidence is sufficient to determine effects on health outcomes, but the strength of the evidence is limited by the number, quality, or consistency of the individual studies, generalizability to routine practice, or indirect nature of the evidence on health outcomes.
• Poor: Evidence is insufficient to assess the effects on health outcomes because of limited number or power of studies, important flaws in their design or conduct, gaps in the chain of evidence, or lack of information on important health outcomes.

Adapted from: U.S. Preventive Services Task Force Ratings: Strength of Recommendations and Quality of Evidence. Guide to Clinical Preventive Services, Third Edition: Periodic Updates, 2000-2003. Agency for Healthcare Research and Quality. Alexandria, VA: International Medical Publishing, Inc.

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