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Empirical Studies

Obesity: Changing the Face of Geriatric Care

October 2006

   Obese Americans exhibit varying forms and degrees of impairment in activities of daily living simply because of their increased body weight, suggesting a relationship between increased body weight and functional limitation.1 As these individuals age, additional obstacles arise due to the natural changes of aging as well as obesity-related comorbidities. In many overweight elderly patients, special accommodations need to be considered in order to promote quality of life. If these issues are complicated by conditions such as incontinence or wounds, additional considerations with options for more creative management may be required.

   The National Health and Nutrition Examination Survey (NHANES) 1999–2000 reports 13% of the US population is over the age of 65; this proportion is expected to reach 20% by 2030. Statistics show that an increasing number of older Americans are carrying extra weight. An estimated 40% of individuals between 60 and 69 years old have a body mass index (BMI) of 30 or more; 30% of persons between 70 and 79 years old are obese.2 Research suggests decreased physical performance and functional limitation are due to elevated BMI.3 Body composition analyses suggest that both excess fat mass and muscle mass loss may be contributing factors to an increased risk for disability. Obesity coupled with the challenges of aging leads to chronic disease, functional decline, and poor quality of life.3 The aim of this review is to address the changing face of geriatric care, including demographics, functional limitations inherent in obesity and aging, and physical assessment and weight management strategies to promote health and wellness, including bariatric weight loss surgery (BWLS). A case study is included to humanize the theory that obese, older Americans have impaired functional limitations because of numerous obesity-related comorbidities along with logistical problems that interfere with activity and mobility.

Functional Limitation

   Research conducted in the US using a longitudinal cohort study design suggests an association between elevated BMI and functional limitations among persons 52 to 75 years old.4 Of interest, however, are seeming discrepancies among studies between gender, disability, and obesity. Friedman et al5 examined BMI and self-reported functional limitations of 7,120 community-based older adults and found that women, but not men, in the highest quintile (one fifth) of BMI were at increased risk for functional impairment. However, both men and women with a BMI >40 had an increased risk for functional limitations. The reason for this gender discrepancy in self-reporting functional limitation remains unclear but may indicate that women either suffer more disability or may simply be more willing to report limitations. Additional considerations regarding gender differences include the fact that women who have a greater BMI also may have more body fat and less muscle than men or that a survival effect may be present — obese men may not live as long to accrue appreciable disability. In any case, this particular study suggests that gender differences exist.5

   On the other hand, a 2004 study6 of 4,232 community-based obese older men ages 60 to 79 years that examined obesity and overweight and their relationship on the burden of disease and disability concluded this population had two times greater risk for either major cardiovascular disease or locomotor disability than men of similar age but desirable weight. This and other studies indicate healthcare professionals should be aware that varying degrees of disabilities can exist among larger, heavier older adults.4,7,8

Health Assessment

   Body mass index. An initial assessment of obesity in older patients should include a measurement of the patient’s height and weight. Body mass index is the result of dividing the patient’s weight in kilograms by height in meters squared and is used to predict mortality and morbidity based on body fat. Body mass index allows comparison between patients of different heights and weights by assigning a numeric value that takes differences into account. Although muscle mass may decline with age, the clinician can use BMI to trend health risks for the older patient.4 Waist circumference also is a useful measurement, especially when the BMI is between 25 and 34.9. A waist circumference >35 inches for women and >40 inches for men increases mortality and morbidity risk primarily because of the health risks associated with excessive visceral fat around the abdominal organs (central obesity).7 Central obesity is associated with cardiovascular disease and insulin-resistant disorders and can be an independent risk factor for hepatic steatosis.8 Additionally, from a practical perspective, activity and mobility can be compromised because of excessive weight located around the abdomen.

   Vascular and skin concerns. An appropriately sized blood pressure cuff should be used when screening for hypertension. If the cuff is too small, blood pressure readings may be inaccurately high.9 A focused skin examination should include assessment for acanthosis nigricans around the neck and axilla, characterized by hyperpigmented, velvety plaques in body folds with lesions that may be warty, leathery, or papillomatous. This chronic dermatosis suggests hyperinsulinemia or malignancy.10 Screenings also should include assessments for cellulitis, intertriginous rashes, or other signs of skin breakdown because a break in the skin surface can provide a port for bacterial invasion. Lower leg edema may indicate right-heart failure or direct compression by an abdominal pannus in the very obese patient.11 A baseline assessment comprised of predictors for mortality and morbidity along with a focused skin assessment can guide the clinician in making choices regarding weight management needs and the complexities of an already at-risk population.

Weight Management

   A 4-year, prospective study12 comprised of 40,098 subjects published in 1999 involving obese (BMI >30) women ages 65 years and older suggested that a weight gain of 20 lb or more was associated with a decline in reported physical functioning and a weight loss of 20 lb or more was associated with improved physical functioning. Among older adults, the crucial challenge involves balancing nutritional requirements with weight loss. Malnutrition is commonly associated with intentional or unintentional weight loss in older adults; weight loss is often considered a symptom of declining nutritional status and potentially poor outcomes and health and, therefore, poses a serious dilemma if mismanaged. Malnutrition is a significant concern for obese older adults because the presence of malnutrition complicates health and wellness, delays recovery from illness, and interferes with successful management of chronic conditions.13

   Heiat et al14 suggest that knowledge about the treatment of obesity in older adults is limited because clinical trials tend to exclude older persons; therefore, the appropriate nature of interventions such as weight loss surgery, low-calorie dietary changes, weight loss medication, or types of physical activity have not been adequately evaluated in this age group. Surgery has recently become as option for weight loss in certain older adults15 (see “Bariatric Weight Loss Surgery”). Low-calorie diets must still meet nutritional needs for older adults with special attention to protein, vitamin D, vitamin B12, fiber, and fluid intake.14

   In a review article based on original research reported in 1994, Campbell et al16 note that protein requirements are higher in elderly persons and additional protein may be required if they are healing or chair- or bedbound.17 If a weight-reducing diet does not provide enough protein and calories to protect the protein stores, muscles waste, immune function may be compromised, healing slows, and new tissue quality is poor. Even with adequate protein, protein tissue may be lost if energy reserves are inadequate.17

   The National Heart, Lung, and Blood Institute now recommends the Dietary Approaches to Stop Hypertension (DASH) diet, which is rich in fruits and vegetables; high-quality lean meats, poultry, and fish; low-fat dairy products; and whole-grain breads and cereals. The diet also includes at least 48 oz of fluid per day.18 This common sense approach has been tested without restriction to age or gender and demonstrates positive outcomes such as decreased blood pressure and weight loss.19 Vitamin and mineral supplements should be considered based on professional recommendation. Older individuals who seek to reduce body weight should be encouraged to seek the help of nutrition professionals such as registered dietitians for advice on how to modify their diets for health and wellness.

   In addition to nutritional changes, activity specifically tailored to the patient’s functional limitations has been found helpful. Safe physical activity needs to be patient-specific to prevent injury. Specially trained physical therapists, kinesiologists, or other experts may be valuable in addressing the patient’s needs. For some, walking programs are beneficial; for others, water exercise or low-impact activities are preferred.20 Establishing the patient’s preferences is important — for example, in some cases, patients tend to be more successful if involved in group activities that incorporate a social aspect. The goal is to consider an activity that promotes long-term positive behavioral change such as long-term commitment to activity patterns that meet physical and economic limitations.21

   Some clinicians suggest the use of drugs to aid in weight loss of elderly patients who have obesity; however, drug therapy for elderly adults may be risky and the benefits gained from weight reduction may be overshadowed by the possibility of polypharmacy, drug-drug interactions, and altered pharmacokinetics.22

   According to Chernoff’s23 review article based on original research, recommendations by the individual’s primary physician, cost, convenience, and health motivation contribute to the success of any weight management and health promotion effort.

Case Study

   Background. Ms. M is 79 years old, 4 feet, 11 inches tall, and weighs 294 lb; her BMI is 59.4. She lives at her home alone (see “Understanding Homebound Status and Obesity”). The majority of her weight is at her mid-section and lower extremities. She has a significant waist-to-hip ratio indicating central or abdominal obesity; this poses an additional risk for morbidity and mortality. Like many older, obese individuals, Ms. M has significant problems with mobility, access to social and health programs, weight management, and meeting her nutritional needs. In combination, these challenges have led to long-standing skin and wound problems. Resources such as clinical experts and tools including size-appropriate, patient-specific equipment have been introduced to address her functional limitations.

   Ms. M is similar to many older women who have functional limitations associated with increased BMI. Simple daily activities are difficult for her and she has trouble with almost every common movement, from rolling over in bed to getting out of a chair. She cannot walk more than 10 to 12 steps without becoming short of breath and often has to sit down to recover.

   Many obese people have lower leg problems, including edema, venous stasis disease, lymphedema, or a large panniculus that interferes with circulation. Ms. M has a long-standing history of unspecified lower extremity problems that began with swelling and progressed to leaking and chronic wounds. Several years ago, she was diagnosed with obstructive lymphedema and venous stasis disease.

    In the course of clinician evaluation comprising history, weight, physical assessment, blood pressure and assessment of other factors, opportunities for improvement in wound management were observed that subsequently would improve functional capacity and overall health. As with any patient with venous stasis disease, compression and leg elevation at rest were key goals to facilitate lymphatic return and decrease swelling. Ms. M had not been able to flex at her waist because of her weight and lacked the fine motor grasp and arm strength necessary to apply compression stockings. Because of her decreased knee and hip range of motion, Ms. M could not raise or physically lift her legs. When she tried to use a recliner to facilitate leg elevation, she could not manually maneuver the chair to the recline position. Resting in bed was an inappropriate alternative — her body weight, weight distribution, and decreased arm strength prohibited her from properly positioning herself. Similar to her problems in the reclining chair, she had a hard time raising her legs and moving them over in bed. Her only alternative was simply to sit, fall back, and roll over to get in bed. Repositioning presented additional challenges.

   Wounds. Locally, Ms. M’s malleolar wounds drained heavily and fluctuated in size (see Figure 1). The wounds appeared clean (no odor or necrotic slough) but failed to improve — likely because her legs were in the dependent position most of the time and she was unable to wear her compression stockings.

The first goal of Ms. M’s wound care was to decrease the size and drainage of the malleolar wounds. To that end, the first issue was leg elevation and compression. A dry, multilayer wrap was applied and changed twice weekly to help reduce the fluid pooling in the lower extremities. Because Ms. M, like many obese older patients, was homebound, the wound care was performed at her home, monitored by a home health nurse. The dry wraps offer sustained compression; a measurable difference was observed. Between weeks 1 and 2, a measurable difference was observed. The next step was to address local wound management — the principles of care included a method to provide absorption of excess moisture, protect the surrounding skin, and promote granulation.

   Physical activity. Although Ms. M’s wounds improved with compression and local care, the challenge of leg elevation was an ongoing issue. An electric recliner with a sit-to-stand feature was introduced not only to provide a means to leg elevation but also to provide the option of mechanically raising Ms. M to a standing position. The benefits of this chair were profound — Ms. M no longer needed to struggle to stand. The sit-to-stand feature had a significant secondary benefit: because she needed far less energy to stand, Ms. M could expend her energy in other ways. The chair also helped her sit without physical stress or injury.

   Ambulation assistance. Occupational therapy assessed her daily living needs and provided guidance for household adaptations. A hospital low bed with split rails, head elevation, foot elevation, and overhead trapeze was provided. Although it was not as wide as Ms. M’s bed, it was more functional and required less independent manipulation to get in and out. The mechanical bed also permitted Ms. M to reposition herself more regularly during the night. The importance of ambulation was explained and a bariatric walker with a seating bench was introduced to help Ms. M move more independently between rooms around her home without becoming short of breath. The walker allowed her to walk with support; thus, decreasing her total physical workload. When she became tired, she was able to sit and rest before continuing with her desired activity.

   Footwear. Because Ms. M was unable to reach her feet or lower extremities, her shoes were evaluated for safe tread and ease of wear. Orthotic slip-on shoes were ordered and adjusted for size to accommodate slip on and off wear. This improved her gait and footing so that, in conjunction with walker use, she had more confidence in her ability to ambulate safely.

   Exercise. Physical therapy evaluated Ms. M’s physical strength. She was taught several hand and upper body exercises to increase hand and arm strength and improve range of motion. These exercises utilized stretchy bands, squishy balls, and chair activities. Once her wounds resolved and her functional limitations improved, water exercise was suggested.

   Weight loss. Weight loss options were discussed. Living alone, Ms. M usually avoided cooking and often ordered take-out or ate highly processed, easily prepared foods. She was not confident she could weigh or measure food or shop regularly for groceries; she opted to try a weight loss program that would deliver prepared meals to her house. She could use her microwave oven to heat the delivered food, an acceptable alternative to cooking and heating up the house.

   Outcomes. Ms. M was committed to numerous behavioral changes and did very well. Despite her advanced age, obesity, chronic conditions, and functional limitations, she reported greater ease in performing some of her daily activities. She said the electric recliner made the greatest difference to her. She reported less fatigue in getting up and down and, therefore, was more inclined to get up and move. She tolerated the leg wraps adn noticed a significant decrease in the lower leg edema, which she atrributed to the leg elevation provided by the elctric reclining chair and the compression wraps. She was better able to negotiate the mechanical bed, which also elevated her legs when resting. Ms. M believed this improved her overall outcome in general and wounds specfically (see Figures 2, 3, 4).

  Ms. M lost 50 lb over the course of 6 months, lowering her BMI from 59.4 to 49.3. She revised her nutritional approach when she found she could purchase prepackaged meals at the market that were less expensive than those delivered daily, making it more likely that she continue with her efforts. Eventually, she was able to leave her house. She started going to the clinic regularly for wound follow-up. Clinic staff members set up a weight chart for her so she could track her progress.

   Ms. M is hopeful her wounds will continue to improve and is increasingly positive about her new-found mobility. Like many obese, older, homebound adults, she often felt isolated and depressed because she was intimidated by the effort to get up and out of the house. Now she can maneuver more freely and has gained some strength as a result of exercise.

Conclusion

   The number of older persons with obesity is increasing and associated with a tremendous burden of chronic disease and disability. Ms. M and other patients like her know first-hand that ill health, dependence, and poor quality of life are inherent to the condition. An awareness of issues facing such patients along with knowledge of assessment tools and weight loss plans/management options framed from an interdisciplinary perspective will well serve the needs of this complex patient population and the clinicians who care for them. Those who provide care to the elderly need to recognize the changing face of geriatrics. Studies to enhance awareness and knowledge of the factors involved in weight management, disease management, and the complex social and physical needs of obese older individuals are needed.

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