How to manage a patient with abdominal bloating, nausea, constipation, heart failure, chronic kidney disease, anemia, hypertension, polyneuropathy, and a pressure injury?

Management of Complex Multi-System Patient with GI Dysmotility, Heart Failure, and Malnutrition

This 102-year-old patient requires aggressive nutritional optimization as the cornerstone of management, with careful fluid balance monitoring and symptom-directed therapy using minimal medications to address the interrelated cascade of malnutrition, heart failure, and gastrointestinal dysmotility.

Immediate Priorities

1. Address Severe Malnutrition (Primary Driver of Morbidity/Mortality)

The critically low albumin (2.7 g/dL) and prealbumin (9 mg/dL) are directly impairing wound healing and contributing to the patient's functional decline. 1

• Dietary modifications should prioritize small, frequent liquid or soft meals given the patient's intolerance to standard supplements and persistent bloating 1
• Consider trial of low-fiber/low-residue diet to reduce mechanical burden on dysmotile gut 1
• Broths are acceptable as tolerated, but must add protein-rich options such as strained cream soups, protein-fortified liquids, or alternative liquid nutrition sources per dietitian 1
• Weekly monitoring of albumin, prealbumin, and body weight is essential to track nutritional trajectory 1, 2
• If oral intake remains inadequate after 1-2 weeks of aggressive dietary modification, consider nasogastric feeding trial since patient is not actively vomiting 1

2. Manage Gastrointestinal Symptoms with Minimal Polypharmacy

The current plan appropriately adds metoclopramide for both nausea and motility, but requires close monitoring 1

• Continue simethicone TID for symptomatic gas relief 3
• Metoclopramide is appropriate for gastroparesis-like symptoms but monitor closely for extrapyramidal effects, especially in elderly patients 1
• Aggressive bowel regimen is critical: stool softener plus gentle stimulant laxative, not PRN but scheduled 1
• Review and minimize medications affecting gut motility: specifically assess if lidocaine patch or other medications have anticholinergic properties 1
• Encourage upright positioning after meals and increased ambulation to facilitate gastric emptying and reduce bloating 1

3. Optimize Heart Failure Management Without Worsening Malnutrition

The trace edema and clear lungs suggest relatively well-compensated heart failure, but diuretic resistance due to poor compliance threatens decompensation. 1

• AM dosing of furosemide is appropriate compromise to improve adherence while maintaining diuresis 1
• Daily weights are mandatory to detect early fluid accumulation 1
• Weekly BMP and magnesium monitoring is essential given CKD stage 3a (eGFR 49) and risk of electrolyte depletion with diuresis 1
• The elevated CO₂ (35-36) suggests chronic compensated metabolic alkalosis from diuretic use - monitor for worsening 1
• Continue ACE inhibitor (lisinopril) and beta-blocker (metoprolol) as these improve mortality in heart failure, even with CKD 4, 5
• Recognize the cardiorenal-malnutrition triad: heart failure worsens kidney function, kidney dysfunction impairs nutrition, and malnutrition worsens both cardiac and renal function 6, 4, 5

4. Address Anemia Contributing to Functional Decline

Hemoglobin of 9.7 g/dL is contributing to fatigue, poor wound healing, and potentially worsening heart failure. 6, 4

• Anemia in this context reflects combined nutritional deficiency, CKD, and chronic disease 6, 4
• Continue multivitamin and vitamin supplementation 1
• Consider checking iron studies, B12, and folate if not recently done to identify correctable deficiencies 6, 2
• Erythropoiesis-stimulating agents may be considered if anemia persists despite nutritional optimization and iron repletion, particularly given CKD 6, 4

5. Pressure Injury Management Depends on Nutritional Recovery

The unstageable sacral wound will not heal without correcting the severe protein-calorie malnutrition. 1

• Continue current wound care with zinc barrier and repositioning q2h 1
• Aggressive mobilization out of bed is critical both for pressure relief and to stimulate appetite/improve gut motility 1
• Nutritional optimization is the rate-limiting step for wound healing - this must be the primary focus 1

Critical Monitoring Parameters

• Daily: Weight, intake/output, bowel movements, symptoms of volume overload
• Weekly: BMP (including magnesium), albumin/prealbumin, CBC
• Ongoing: Functional status, oral intake documentation, wound assessment

Key Pitfalls to Avoid

Do not delay nutritional intervention waiting for GI symptoms to fully resolve - the malnutrition is life-threatening and requires immediate aggressive management 1

Do not discontinue diuretics due to patient preference - volume overload will precipitate acute decompensated heart failure and further decline 1

Do not add multiple prokinetic agents simultaneously - use metoclopramide first, assess response, then consider alternatives if ineffective 1

Recognize this patient needs multidisciplinary team involvement including dietitian, wound care specialist, physical therapy, and potentially palliative care given age and complexity 1

If nutritional status does not improve within 2-3 weeks despite aggressive oral interventions, escalate to enteral feeding rather than allowing continued deterioration 1