Nutrition in Older Adults

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Nutrition in Older Adults

• The Aging Impact

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Objectives

• Understand the importance of proper nutrition in
  the older adult
• Discuss the effect of aging on the nutritional
  needs of the older adult
• Identify factors that affect nutrition in the
  elderly
• Understand nutrition assessment
• Discuss nutrition intervention for the elderly

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Proper Nutrition

• Enough intake of essential nutrients to maintain
  good health..
• Carbohydrates
• Fat
• Protein
• Vitamins
• Minerals
• Water
• Nutrients are needed for energy, preventing
  disease, and maintaining a healthy body.

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Importance of Proper Nutrition

• Strong relationship between nutritional status
  and health
• Malnutrition increases incidence of illness,
  length of recovery and even mortality
• Early recognition of malnourishment leads to
  improved short and long-term health

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The Aging Population

• By 2050, 1 in 5 Americans will be gt65 yrs of age
• A large portion of this population will have
  annual incomes of 10,000 or less
• Adversely affects access to food and food choices
• Many will be at least 10 underweight
• Presents long term challenges to health care

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Demographics of Nutrition in Older Adults

• Community
• 16 consume lt1000 kcal daily
• Protein, calorie , vitamin deficiencies common
• 30 men, 40 women underweight after age 75
• Widows lost 7.8 pounds on average in two years
  after loss of spouse

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...Demographics

• Hospital
• 50 of those over 65 are malnourished at
  admission
• 66 are malnourished at discharge
• Nursing Facility
• 40-85 are malnourished
• 50 of those with dementia are underweight
• 45 minutes average to feed one individual

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Changes in Aging

• Anabolic vs. catabolic
• Decreased efficiency and impaired organ function
• Loss of lean body mass
• Decrease in energy needs compared to younger
  adults
• Decrease in senses
• Generally seen in gt60-70 yrs

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What happens when the senses go?

• Induce changes in secretions
• Salivary
• Gastric acid
• Pancreatic
• Impair metabolic processes

• Hearing loss/ Impaired vision
• Decreased food intake, appetite, and food
  recognition
• Inability to feed oneself

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Macro Nutritional Deficiencies

• Weight loss associated with decline in bone
  mineral density
• Protein energy undernutrition
• Increased hospitalization
• Susceptibility to infection
• Postural hypotension
• Pressure ulcer risk

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Micro Nutritional Deficiencies

• Calcium osteoporosis
• Vitamin D osteoporosis
• Folate anemia, cognition
• Iron anemia
• Magnesium immuno-deficiencies
• Vitamin B12 cognition, neuropathies

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Free Radicals and Aging

• Contribute to cellular aging
• Fat and high caloric diets increase free radicals
• Antioxidants inhibit free radicals
• Vitamin E
• Vitamin C
• Vitamin A
• Selenium

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Poor Dentition

• Xerostomia
• Lack of salivation
• Affects 70 of elderly
• Decreases fluid intake because lack of thirst
  mechanism

• Dentures
• Chew 75-85 less efficiently
• Decreased intake of meat, fresh fruit, and
  veggies
• Fe, Vit C, Folate, beta-carotene

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Gastrointestinal Changes

• Decrease in peristalsis
• Decrease absorption in small intestine
• Alteration in certain hormone levels
• Decrease in Ca absorption
• Hypochlorhydria
• Correlated with age, Increases pH and alters
  absorption of B12

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Constipation

• Altered GI motility
• Poor muscle tone
• Inadequate fluid intake
• Inactivity
• Decreased energy intake (poor fiber)

• Laxative use
• 8.8 of elderly in community
• 74.6 of Nursing home residents
• Increases with age

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Other Changes

• Metabolic
• Glucose tolerance
• Increase 1.5 mg/dL per decade

• Musculoskeletal
• Sarcopenia Change in body fat
• Decreased body fat
• Osteoporosis short stature

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Nutritional Risk Social Issues

• Isolation
• Depression
• Immobility
• Fear of crime
• Dental problems
• Inadequate income

• Alcoholism
• Nutrient intake
• Metabolized by liver into acetate that is used to
  form triglycerides
• Intake amount effects fat mass
• Common deficiency
• Thiamine
• Folate
• Pyridoxine

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Other Risk Identifiers

• Inappropriate food intake
• Known weight loss
• Gradual weight loss is common
• lt10 weight loss in 6 months is significant for
  malnutrition
• Limited literacy
• Dependence, disability
• Acute and chronic disease
• Perioperative status
• Medication use

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Nutritional Assessment Scales

• DETERMINE Your Health
• http//www.nestleclinicalnutrition.com/frameset_so
  lutions_mna.html
• Meals on Wheels
• http//www.fpnotebook.com/END31.htm
• Mini Nutritional Assessment
• http//www.nestleclinicalnutrition.com/frameset_so
  lutions_mna.html
• Dysphagia Evaluation
• http//www.mmhc.com/nhm/articles/NHM9912/cefalu.ht
  ml

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DETERMINE Checklist for Malnutrition

• Disease
• Eating poorly
• Tooth loss or oral pain
• Economic hardship
• Reduced social contact
• Multiple medications
• Involuntary weight loss/gain
• Need of assistance with self-care
• Elderly person older than 80 yrs of age

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Questions From DETERMINE List

• I eat fewer than 2 meals per day
• I eat few fruits and veggies
• I have 3 or more alcoholic drinks/day
• I have difficulty chewing/swallowing

• I eat alone
• I take more than 3 prescribed meds/d
• I have lost or gained 10 pounds in 6 mo
• I am not physically able to shop

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Geriatric Assessment of Nutritional Status

• Weight, weight status
• Skin turgor and appearance
• Mental health status
• Physical disabilities
• Hemoglobin, Hematocrit
• Serum albumin, lipids, glucose
• UA for glucose, ketones, protein, occult blood

• Bowel and bladder function
• Past present medical history
• Dietary History
• Use of medications, laxatives, supplements
• Living arrangements, social life, income
• Activity pattern frequency

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Clinical Observations

• General appearance
• Normal, alert and responsive
• General vitality
• Endurance, energy, good sleep habits
• Weight
• Look at height, age and body build
• Muscles
• Well developed, firm
• good tone,
• some fat under skin

• Posture
• Erect
• Skeleton
• No malformations
• Bowlegs, knock-knees, chest deformity
• Legs, feet
• No edema, tenderness or tingling
• Good color
• Nails
• Firm, pink, no spoon shape or ridges

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Clinical Observations

• Skin
• Smooth, moist, good color
• Hair
• Shiny, healthy scalp
• Face and neck
• Uniform color, healthy, no swelling
• Eyes
• Bright, clear, shiny
• Mouth
• Lips smooth, moist, good color
• Gums pink, healthy,
• Tongue pink to red, smooth

• Nervous system control
• Good attention span,
• not irritable or restless,
• normal reflexes
• Gastrointestinal function
• Good appetite and digestion
• Regular elimination pattern
• No palpable organs or masses
• Cardiovascular function
• Normal rate and rhythm, blood pressure

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Diagnostic Tests for Nutrition

• Albumin
• Pre albumin
• Transferrin
• Total Lymphocyte count
• Serum cholesterol

• lt 3.5 mg/dl
• variable
• lt 200 mg/dl
• lt 1500 cm3
• lt 150 mg/dl

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Body Mass Index (BMI)

• Weight in kg/Height in m2
• lt18 Underweight
• 18.1-25 Normal
• 25.1-30 Overweight
• 30.1-35 Obesity class 1
• 35.1-45 Obesity class 2
• gt45.1 Morbidly Obese
• Mortality increased with BMI lt 20 gt 25

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Nutrition Related Conditions

• Unintended weight loss
• Dehydration
• Pressure ulcers
• Anorexia of aging
• Failure to thrive

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Unintended Weight Loss

• Warning Signs
• Needs help to eat/drink
• Eats lt ½ of meals
• Mouth pain
• Poor denture fit
• Difficulty chewing or swallowing
• Trouble using utensils
• Wanders or paces
• Crying, sad, withdrawn

• Action Steps
• Alert HC provider
• Examine oral cavity
• Evaluated swallow
• Request dietary consult
• Request OT consult
• Assess impact of meds
• Develop strategies to increase food intake

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Dehydration

• Warning Signs
• Drinks lt 6 cups of liquid daily
• Needs help to drink
• Trouble swallowing liquids
• Is dizzy, easily confused or tired
• Dry mouth, cracked lips, sunken eyes
• Urine is dark in color or has a strong odor
• Fever, vomiting, diarrhea

• Action Steps
• Review VS
• Assess hydration status
• Alert HC provider
• Treat underlying conditions
• Identify and implement strategies to assist with
  drinking
• Implement scheduled hydration plan
• Assess medications

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Pressure Ulcers

• Warning Signs
• Incontinence
• Heavy perspiration
• Needs help with mobility and positioning
• Weight loss
• Dehydration

• Action Steps
• Alert HC provider
• Follow WC protocol
• Assess underlying conditions
• Implement mobility, positioning program
• Follow UWL and D interventions

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Anorexia of Aging

• Loss of appetite
• Lack of desire to eat
• 10 weight loss in 6 months
• Differentiate from food intolerance
• Rule out early satiety
• May be normal at end of life

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Factors Relating to Anorexia of Aging

• Decreased vision
• Decreased sense of smell
• Decreased feeding drive
• Decreased taste
• Poor dentition
• Decreased ability to self feed

• Dementia
• Decreased ambulation
• Constipation
• Increased effort of breathing
• Cardiac cachexia
• Early satiety
• Slowing of gastric emptying

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Interventions for Anorexia

• Food preferences
• Compatible table companions
• Adequate rest and sleep
• Maximize calories at best meal
• Consume liquids at end of meal
• Avoid gassy foods
• Manage constipation, diarrhea
• Promote oral health
• Emotional support for family at end of life

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Non Nutritional Interventions

• Psychiatric treatment for depression
• Social activity
• Exercise, fun activity
• Social relatedness
• Caring touch, massages, dancing, eye contact
• Family video/audiotapes
• Family therapy
• Phone volunteers
• Email pen pals

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Failure to Thrive (FTT)

• 1890 Described malnourished infants
• 1970 Yale University described older adults
• Rapid weight loss, listlessness, death
• Physiological
• Psychological
• Social

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Organic Etiology (FTT)

• Malignancy
• Tuberculosis
• Heart Failure
• Uremia
• Cirrhosis
• Emphysema
• Chronic obstructive pulmonary disease
• Inflammatory bowel disease

• Thyroid disease
• Diabetes mellitus
• Cushing's disease
• Addison's disease
• Connective tissue disease
• Gastrointestinal dysfunction
• Malabsorption
• End of life

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Non Organic Etiologies FTT

• Neglect
• Abuse
• Immobility
• Dementia
• Depression
• Psychosis
• Medications
• Poor dentition

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Maximize Independence

• Tremors use heavy handled spoon
• Arthritis larger handles on utensils
• Stroke
• Rocker bottom knife
• Deep dish plate
• Avoid special diets

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Nutrition in Dependency

• Maximize dining experience
• Minimize noise, odors, distractions
• Appropriate chair to table height
• Nutritional assistants
• Appropriate diet consistency
• Medicate as needed for pain or discomfort

• Encourage frequent meals/snacks
• Encourage fluid intake
• Obtain frequent weights
• Use of supplements if poor intake
• Utilize the expertise of your Dietitian
• Appetite stimulants as appropriate

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Food Pyramid for Older Adults
Gerald J. and Dorothy R. Friedman School of
Nutrition Science and Policy.
http//nutrition.tufts.edu/publications/pyramid.sh
tml