Nutrition
and the
Elderly
Sandra Stork MS, RD, LMNT
Nutrition and the Elderly
• Why study
nutrition and the
elderly?
Definition of Terms
• OLD – usual categorization
– Young Old – 65 -74
– Middle Old – 75 – 84
– Old Old
- 85 and older
• HETEROGENEOUS POPULATION
IQ Pre-Test
• IQ = Inquiry
Quotient
• Test your
knowledge and
stimulate your
interest and
inquiry.
Topics
• Changes of Aging
Related to Nutrition
• Geriatric Problems
• What’s “new” in the
“old”?
Objectives
After presentation, discussion,
and completing practice problems,
you will be able to:
• Describe the “Guiding Principles” of
Nutritional status and care in the elderly.
• Identify nutrients pertinent to elderly.
• Review the physiologic changes of aging
which impact nutritional status and care.
Objectives
• Identify the association between selected
Geriatric Problems and nutrition:
– Sarcopenia
– Dehydration
– Dementia
– Constipation
-Weight Loss
-Swallowing
-Pressure Ulcers
-Depression
• Develop strategies for the treatment of
these problems.
• Reduced Nutrient Reserves
• Reduced Response to Stress
Nutritional Care in Geriatrics
Geriatric Problems
• What geriatric
problems impact
nutritional
status?
Sensory Changes with Aging
Sensory Changes with Aging
• Decreased sense of smell due to
decreased olfactory cells
• Decreased vision
• Hearing loss
• Tactile loss
Sensory Changes with Aging
• Decreased number of taste buds
– i Loss of sweet
and salty
– Less loss of bitter
and sour
– ? Umami
– ? Piquant
– Dry mouth prevents
adequate tasting
Psycho-Social Changes of Aging
Psycho-Social Changes of Aging
• Economic
– Less income; less money for food
• Social – Lack of Socialization
– Loss of mobility; can’t drive
– Loss of friends and loved ones
• Psychological
– Loss self-worth; value
– Depression; BIG problem
(Bayer quote)
Depression ……………
The attitude that:
“Of course he/she is depressed, I’d be
depressed too if I were that old and had all
those problems…..”
puts elderly at risk of not receiving clinical
attention for a very treatable disorder. Just
because it is “understandable”, does not
mean that depression is inconsequential or
normal as people age.
Barb Bayer, RN, MSN, CS
Depression ……………
is the most common psychiatric condition
affecting the elderly, but it is often
unrecognized and untreated. The myth that
depression is just a natural part of aging is
widespread in our youth-oriented society. It
is also a belief held by many elderly
themselves, their families, and unfortunately,
many health care professionals.
Geriatric Problems
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Weight Loss
Sarcopenia
Dehydration
Swallowing
Dementia
Pressure Ulcers
Constipation
Depression
Optimal Weight
• Weight is Primary Parameter
• Standard Tables vs. TRENDS
– Identify unintentional weight change
– Attention to trends
• Optimal Weight
– Maximize function and quality of life
– Minimize disease risk
Usual Weight Trends
Epidemiology
• Gradual Weight Gain – Middle Age
• Peak Weight at 75 years
• Gradual Weight Loss
after age 75
Unintentional Weight Loss
• Weight loss >5% in 30 days
• >7.5% in 90 days (three months)
• >10% in 180 days (6 months)
• Example:
– 5% 7-8# in 154# = 146#
– 10% 15# in 154# = 139#
Long Term Care Guidelines
American Healthcare Association
Identifying Weight Change
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Weight History
Change in Clothing Fit
Decrease in Functional Ability
Dietary Intake Records
These methods are readily
accessible and cost effective
Impact of Weight Loss
• Most indicative screening
parameter
• Greater clinical significance
• Less reserve capacity
• Difficulty regaining weight
• Loss of functional ability
Weight and Mortality
Potter, et al, 1988
Corrada, et al, 2006
Strategies: Calories
Rule of Thumb
• Energy needs are dependent on activity and
physiologic stress levels
• 25-30 kcal/kg
• Basal Energy Equation X factor of 1-1.5
– Harris Benedict Equation
– Mifflin St-Jeor Equation (Currently recommended)
Strategies: Calories
• Avoid unnecessary dietary
restrictions
• Encourage use of
nutrient dense foods
• Use more frequent meals plus
supplements or snacks
Strategies: Calories
Practical Suggestions
• Use foods that are well liked
frequently
• Provide double portions of
favorite foods
• Add calories by using sauces,
gravies, toppings, and fats
• Emphasize calorie containing
liquids to meet fluid needs
Obesity
•
h numbers reaching older age as obese
(30.5% in NHANES)
h physical and cognitive disability
• h risk of dependency and
•
institutionalization
•
h health care costs, poor health
outcomes, mortality
Houston, et al, JADA, Nov. 2009
Obesity Treatment
• Goal: To better manage health and
maintain independence longer
• Minimize loss of muscle mass
– Adequate protein
– Exercise (aerobic and resistance)
• Minimize loss of bone density
– Adequate calcium, Vitamin D
– Exercise (weight bearing)
• Adequate nutrient intake
Sarcopenia
• Definition: Loss of muscle mass in aging.
• Results: Lower basal metabolic rate
– Weakness
-Decreased Functional Status
– Reduced Activity Level
– Decreased Bone Density
• Practical Application
– Progressive Resistance Exercises
– Adequate Protein
Protein
•Higher protein intake required
to maintain nitrogen balance
•Contributors:
–Lower energy intake
–Impaired insulin action
–Decreased efficiency of
protein utilization
J.Nutr.Healthy Aging, 2006
Protein
•1.0-1.25 gm/kg/day
•At least one high protein food
at each of three meals
•Physical activity to maintain
muscle mass
-Exercise against resistance
Protien
Practical Suggestions
•Add nonfat dried milk solids
•Add cheese, peanut butter,
eggs and nuts (if dentition
permits)
•Use commercial protein
powders or supplements
Geriatric Problems
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Weight Loss
Sarcopenia
Dehydration
Swallowing
Dementia
Pressure Ulcers
Constipation
Depression
Dehydration: Causes
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Decreased thirst sensation with aging
More dependent on others to obtain fluid
Decreased ability to concentrate urine
Increased incidence of incontinence with
self-imposed fluid restriction
• Increased use of medications contributing
to dehydration
• Increased losses: vomiting, diarrhea, fever
Dehydration: Symptoms
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Decreased Skin Turgor
Dry Mouth and Mucosal Membranes
Decreased Urine Volume
Darker Urine
Constipation
Acute Weight Loss
CONFUSION
Dehydration
Practical Application
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Treat Cause
Set Fluid Goal
Goal: 30 cc/kg or 1 cc/Kcal
Replace Additional Fluid Losses
Drink Fluid At and Between Meals
Use Foods Which Have Fluid Value
Fluids
• Which fluid
is the best
fluid?
Fluid:Nutrient Comparison
Fluid
Free Water (cc) Calories/Protein
Water
240 cc (100%)
0/0
Juice (Apple)
210 cc (88%)
111/0
Whole Milk
214 cc (89%)
150/8
Instant
Breakfast
Fruit Beverage
Supplement
217 cc (80%)
250/13
191 cc (79%)
300/10
Fluids
• What about
caffeine for the
elderly person?
• Have a balanced
approach.
• Caffeine naivety.
Journal American College of Nutrition, 2003
Swallowing Problems
S
Swallow is difficult or hard to initiate
W Wet sounding voice
A
Aspiration pneumonia in history
L
Loss of fluid through the nose
L
Leakage of food or liquid out of mouth when eating
O Overt coughing or choking with oral intake
W Weight loss with inadequate nutritional intake
I
Involve Speech Pathologist and others
N Nutrient Density
G Go for Least Restrictive
Swallowing
Practical Application
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Be Alert to Symptoms
Consult Speech Pathologist
Involve Dietitian/Nutrition
Appropriate Fluid and Nutrient Density
Geriatric Problems
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Weight Loss
Sarcopenia
Dehydration
Swallowing
Dementia
Pressure Ulcers
Constipation
Depresssion
Dementia
• Weight Loss Primary Nutritional Problem
• Stage of Disease Important
• Eating Behaviors
Eating Behaviors: Overview
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Eating is NOT just food
Barometer of well being
Social interaction
Symbolic of life
Eating Behaviors: Examples
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Distracted at meal times
Eat non-finger foods with hands
Consume non-food items
Eat pieces that are too big
Incorrect use of utensils
Resistive to eating
Principles of Management
• Assess problems
• Utilize creative strategies to address
individual problems
• Think OUT OF THE BOX
• Alternate strategies
• Continue reassessment process
• Multidisciplinary approach
Eating Behaviors: Questions?
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What is being said by behaviors?
Are behaviors harmful?
What precipitated the behaviors?
Is there an unmet need?
What are potential causes?
Eating Behaviors: Strategies
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Consistent eating patterns
Quiet environment
Sit when feeding
Only food items on table
Cut and season food prior to serving
Provide (double) favorite foods
Provide verbal and tactile cueing
Geriatric Problems
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Weight Loss
Sarcopenia
Dehydration
Swallowing
Dementia
Pressure Ulcers
Constipation
Depresssion
Pressure Ulcers
• Screening Tool: (Example – Braden Scale)
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Sensory Perception
Moisture
Activity
Mobility
Friction and Sheer
– Nutrition
• Cooperation and Collaboration Needed
– Nutrition is only one component
Pressure Ulcers: Nutrition
• Protein: 1.25 to 2.0 gm/kg
• Vitamin/Mineral Supplementation
– Useful with poor intake or depletion
– Vitamin C: 1 to 2 gm/day
– Zinc Sulfate: 220 mg/day
Geriatric Problems
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Weight Loss
Sarcopenia
Dehydration
Swallowing
Dementia
Pressure Ulcers
Constipation
Depression
Robertson’s Rule of 2’s
Food Item
Amount
Dietary Fiber
100% Bran cereal 1/2 cup or
or Miller’s Bran
2 Tablespoons
10-14 grams
Whole Wheat
Bread
2 slices
4 grams
Fresh Fruit
2 pieces
4 grams
Vegetables
2 servings
4 grams
Total
22-26 grams
Fiber Supplementation
•Alleviation of
constipation
•Crude fiber content
increased by 6-8 gm
•60% residents
•JAGS, 1980, 28:410
•Increased stool
frequency
•Fiber increased 3-12 gm
•Decreased laxative use
•JADA, 2003,103:1199
Geriatric Problems
Principle:
Avoid
unnecessary
dietary
restrictions.
Nutrients of Concern in the Elderly
• Calories
– Nutrient Density
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Protein
Calcium
Vitamin D
Supplements?
• Don’t forget
– Fiber
– Fluids
Osteoporosis
•High incidence of osteoporosis
–33% of women 60-70 years old
–66% of women > 80 years old
•Less efficient absorption of
calcium and Vitamin D
•Reduced exposure to sun =
reduced conversion of
inactive D to active D
•Supplementation essential
–1200-1500 mg/day
Vitamin D
• Most tissues and cells have Vitamin D
receptors
-Skeletal muscles, brain, prostate, breast,
colon, immune cells
• Active D controls more than 200 genes
which are responsible for:
-Cell proliferation, differentiation,
apoptosis, angiogenesis
• Potent immunomodulator
Serum 25-hydroxyvitamin D
• <20 ng/mL
Deficiency
• 20-29 ng/mL
Insufficiency
• 30-80 ng/mL
Optimal Level
• >80 ng/mL
Possible Toxicity
Prevelance of Deficiency
• 40 to 100% of U.S. & European
elderly men & women living in
the community are deficient in D
• >50% of postmenopausal women taking
medication for osteoporosis have
suboptimal levels of D
(<30 ng/mL)
Prevention & Maintenance
• 800-1000 IU Vitamin D3 per day
• 50,000 IU Vitamin D2 every two
weeks or every month
• Daily sun exposure
5 to 30 minutes
10 am to 3 pm
Treatment of Deficiency
• 50,000 IU of Vitamin D2 weekly
for 8 weeks
• Repeat for another 8 weeks if
25-hydroxyvitamin D <30ng/mL
Oral Supplementation
• Cochrane Systematic Review
• Effectiveness of nutritional supplements
in elderly at risk for malnutrition
• Review of 62 trials
– 10,187 randomized patients
– Maximum duration of intervention: 18 months
•Milne, AC, et al, Protein and energy
supplementation in elderly people at risk from
malnutrition. Cochrane Database of Systematic
Reviews, 2009, Issue 2.
Oral Supplementation
• Significantly improved mortality in
undernourished
• Small, consistent weight gain in 42 trials
• Reduced risk of complications in 24 trials
• No evidence of functional improvement
• No reduction in Length of Stay
Oral Supplementation
Practical Suggestions
• Product Acceptance
• Taste Fatigue
• Supplementation not Meal Replacement
Oral Supplements
• Carbohydrate Powder
– Polycose (23 kcal/Tblsp)
• Protein Powder
– Beneprotein (6 gm protein/packet)
• Carbohydrate & Protein
– Benecalorie (330 kcal & 7 gm protein/1.5 oz)
– ProMod (100 kcal & 10 gm protein/1 oz)
Oral Supplements
100 kcal/1 oz
6 gm/pkt
10 gm protein
330 kcal/1.5 oz
7 gm protein
23 kcal/Tbl
Vitamin/Mineral Supplements
• A daily multivitamin mineral
supplement is recommended
• Geriatric Vitamins
+ Vitamin C,D,E
+ Vitamin B6
+ Vitamin B12
- Iron
Cholesterol in the Elderly
• Serum cholesterol used to identify
malnutrition in the elderly
• Serum cholesterol below 150 indicative of
malnutrition
“NEW” Information
• What’s “new”
in the “old”?
Appetite Stimulation
Sensory Changes with Aging
• Decreased sense of smell due to
decreased olfactory cells
• Decreased number of taste buds
• Decreased vision
Appetite Stimulation
Benefits to Increasing Appetite
• Reverse anorexic cycle
– Failure to eat
– Ketone build up
– Loss of appetite
• Promote Nitrogen Balance
• Further stimulate appetite
• Consider tube feeding; night feeding
Appetite Stimulation: Research
• Megestrol Acetate (MA)
• N= 51 men; Average Age 76
• Weight loss > 5% in 3 months or > 20%
below “ideal” weight
• 800 mg MA/day
• 12 weeks on MA; 13 weeks off MA
• Weighed monthly
• Control – no MA
Research Results
• 12 weeks on MA – No significant wt. gain
• 13 weeks after MA – Wt. gain (> 4#) was
significantly increased in MA patients
• 38% of MA pts did not gain wt; wasted,
advanced dementia; more medical
conditions; greater than 10 medications
• All who gained wt, gained lean body mass
• ?? Functional Benefit ??
Research Conclusions
• In geriatric patients, MA may promote
weight gain, but anticipate a delayed
response
• Initiate treatment early
• 800 mg was tolerated by elderly patients
“Vittles, Vitamins & the Vintage Old”:
Macular Degeneration
• Studies in the elderly suggest that the use of
large doses of certain vitamins and minerals
are beneficial in the prevention of macular
degeneration
• Some evidence exists that improvement in
existing damage may be seen
“Vittles, Vitamins & the Vintage Old”:
Macular Degeneration
Vitamin/
Mineral
A
Amount
% DV
14,320 IU
286
C
235 mg
371
E
200 IU
667
Zinc
348 mg
232
Copper
0.8 mg
40
WARNING
Vitamin A Intake
• Vitamin A directs the process of borrowing and
redepositing calcium in the bone
• Too much preformed Vitamin A (retinol) can
promote fractures.
• Use Vitamin A in form of beta-carotene, a precurser form which does not increase fracture
Topics
• Changes of Aging
Related to Nutrition
• Geriatric Problems
• What’s “new” in the
“old”?
Post - Test
• What is one
“NEW” thing
that you have
learned that you
did not know before?