NS325 Unit 8 Older Widow Case Study Example

One Real Meal a Day: A Unit 8 Older Adult Case Study of a Widow Whose Denture, Reflux Medicine and Warfarin Share One Plate

[Student Name]

Purdue University Global

NS325: Nutrition Through the Life Cycle

Unit 8 Older Adult Case Study

[Instructor Name]

[Date]

The woman, her history, measurements and medicines are composite; the protein position paper, acid suppression study, warfarin interaction review and B12 reference intake cited are real.

Presentation

E.K. is 83 and lives by herself in a walk-up apartment, one floor above the street, in Anderson, Indiana. Her husband died two years ago. She worked as a school cook for thirty years and still enjoys cooking, but now cooks only on Sundays. Her daughter drove her to a senior center health fair, where a nursing student weighed her and suggested a nutrition visit.

Measured values: weight 57.2 kg, against 61.3 kg recorded at her physician's office five months earlier, a loss of 4.1 kg or 6.7 percent. Height 160 cm, body mass index 22.3. A one-day recall showed about 1,150 kcal and 38 g of protein: tea and toast at breakfast, canned soup and crackers at lunch, and a small portion of Sunday's casserole in the evening.

Medicines: omeprazole, 20 mg each morning, taken for reflux since six years ago, and warfarin for atrial fibrillation, with her international normalized ratio checked monthly. She also takes a daily multivitamin "when I remember."

Assessment by Domain

Appetite and eating. Her lower denture rubs a sore spot on her gum, so she steers clear of meat, raw vegetables and other foods that take hard chewing. Food "tastes like nothing," which she attributes to age. She eats alone and says cooking for one feels pointless. The stairs make shopping a weekly trip with her daughter.

Nutrient adequacy. Her protein intake of 38 g is about 0.66 g per kilogram, below the adult RDA of 0.8 g/kg and well below the 1.0 to 1.2 g/kg suggested for healthy older adults by the PROT-AGE group (Bauer et al., 2013). Her energy intake does not cover her needs, as her weight loss confirms. Her diet is low in vitamin B12 sources apart from a little milk in her tea.

Medicines. Long-term acid suppression is associated with vitamin B12 deficiency: in a large health system study, people who had received two or more years' supply of a proton pump inhibitor had higher odds of a new B12 deficiency diagnosis (Lam et al., 2013). Warfarin's effect depends partly on vitamin K intake, and sudden changes in leafy green vegetables or vitamin K supplements can move the INR (Holbrook et al., 2005).

Where the Domains Meet

The case's problems feed one another.

1. Chewing narrows the diet. The sore denture pushes her toward soft, low-protein foods such as toast, soup and crackers, which lowers protein and B12 intake at the same time.

2. Acid suppression lowers what she absorbs. Stomach acid helps free vitamin B12 from the proteins in food. Six years of omeprazole may reduce how much B12 she can absorb from the small amounts of meat and dairy she still eats. Older adults already absorb food-bound B12 less well, which is why the reference intakes advise those over 50 to get most of their B12 from fortified foods or supplements (Institute of Medicine, 1998).

3. Erratic eating unsettles warfarin. Her prescriber set her warfarin dose against her diet at the time. If she now eats greens on Sundays only, or begins eating many more vegetables after advice to "eat better," her INR could swing. Consistency of vitamin K intake matters more than the amount.

4. Taste and loneliness lower intake further. Flat taste and eating alone both reduce the pleasure that drives eating, so the meals she does eat are small.

Each problem on its own looks minor, a sore gum, an old prescription, a lonely kitchen, but together they push her toward soft, low-protein food that she absorbs poorly and eats too little of, which is why she has lost nearly 7 percent of her weight in five months.

Function, Access and Daily Routine

Her day shapes her intake as much as her teeth do. She rises at 7:00, makes tea and toast, and spends the morning with the television and a crossword. Lunch is whatever can be heated in one pot. She climbs the stairs once a day to collect the mail and stops halfway to rest. Her daughter visits on Sundays, and that is the day she cooks a casserole, eating from it until Wednesday and then returning to soup.

Shopping is the bottleneck. Because she shops once a week with her daughter, fresh foods that spoil quickly, such as fish, soft fruit and fresh meat, rarely make it into the cart, and canned and dried foods fill the gaps. She lives on a pension and Social Security and says money is "tight but fine," though she buys store-brand soup by the case because it is cheap. A home-delivered meal program, or a grocery delivery service her daughter could order online, would change what is in the kitchen without adding trips on the stairs.

Monitoring

Progress would be judged by four measures over the next three months: monthly weight on the same scale, a repeat recall after any meal service begins, her INR results from the anticoagulation clinic, and the result of any B12 test her physician orders. A further loss of more than 2 kg, or any INR outside her target range, would prompt an earlier review.

Priorities

1. Protein and energy. A 6.7 percent loss in five months is significant. Soft protein foods that suit her teeth, such as eggs, yogurt, cottage cheese, beans, flaked fish and ground meat in sauces, can raise intake without chewing.

2. Vitamin B12 status. Her physician should be asked to consider checking B12, given her age, diet and long-term omeprazole.

3. Warfarin consistency. Any change in her diet, particularly in leafy greens, should be steady and shared with the clinic that manages her INR.

4. The denture. A dental visit to adjust the denture would remove the first link in the chain.

Referrals

1. Dentist, for denture adjustment.

2. Her physician, about B12 testing and whether long-term omeprazole is still needed, a decision that rests with the prescriber.

3. Anticoagulation clinic, informed of any planned diet change.

4. Registered dietitian, for an individualized plan.

5. Senior center congregate meals or home-delivered meals, to address eating alone and the stairs.

What the Case Does Not Settle

One recall cannot show her usual intake. Her flat taste may have causes beyond age, including medicines or zinc status, which a clinician would consider. Her weight five months ago came from a different scale. The case identifies priorities and the professionals who should address them; it does not make medical decisions.

References

Bauer, J., Biolo, G., Cederholm, T., Cesari, M., Cruz-Jentoft, A. J., Morley, J. E., Phillips, S., Sieber, C., Stehle, P., Teta, D., Visvanathan, R., Volpi, E., & Boirie, Y. (2013). Evidence-based recommendations for optimal dietary protein intake in older people: A position paper from the PROT-AGE Study Group. Journal of the American Medical Directors Association, 14(8), 542-559. https://doi.org/10.1016/j.jamda.2013.05.021

Holbrook, A. M., Pereira, J. A., Labiris, R., McDonald, H., Douketis, J. D., Crowther, M., & Wells, P. S. (2005). Systematic overview of warfarin and its drug and food interactions. Archives of Internal Medicine, 165(10), 1095-1106. https://doi.org/10.1001/archinte.165.10.1095

Institute of Medicine. (1998). Dietary reference intakes for thiamin, riboflavin, niacin, vitamin B6, folate, vitamin B12, pantothenic acid, biotin, and choline. National Academies Press. https://doi.org/10.17226/6015

Lam, J. R., Schneider, J. L., Zhao, W., & Corley, D. A. (2013). Proton pump inhibitor and histamine 2 receptor antagonist use and vitamin B12 deficiency. JAMA, 310(22), 2435-2442. https://doi.org/10.1001/jama.2013.280490