NUTRITION AND AGING
FACILITATED FEEDING OF
THE OLDER PATIENT
James S. Powers, MD
Meharry Geriatric Education Center
VA Tennessee Valley GRECC
Vanderbilt Senior Care Service
MALNUTRITION PREVALENCE
• community surveys - 33% BMI<24kg/m2;
13%>4% wt loss
• hospital surveys - 61% met 2/4 criteria; 31%
severe; 55%<90% ht/wt norms
• nursing home surveys - 30-60% underweight;
15-60% low plasma proteins
ADVERSE EFFECTS OF
NUTRITIONAL PROBLEMS
• J shaped curve between death and BMI
• curve nadir at BMI 19-27
• difficult to control for confounding effects
Multivariate Relative Risk of Death from All
Causes among Men According to Body-Mass
Index, Smoking Status, and Disease Status
Relative Risk of Death
3
2.5
2
Smokers
Nonsmokers
1.5
1
0.5
0
18 20 22 24 26 28 30 32 34 36 38 40
Body-Mass Index
Multivariate Relative Risk of Death from All
Causes among Women According to Body-Mass
Index, Smoking Status, and Disease Status
Relative Risk of Death
2.5
2
1.5
1
Smokers
Nonsmokers
0.5
0
18 20 22 24 26 28 30 32 34 36 38 40
Body-Mass Index
Chi-square and Multiple Linear Regression Tests of
Albumin (> 3.5 g/dL), Age (>65 years), and Outcome Variables
Disposition
Home
Nursing home
Boarding home
Rehabilitation
Transfer to Acute Care
Death
Total patients
Alb vs diagnosis
Alb vs age
(>65)
Age vs disposition, length
of stay, diagnosis
% ALB >3.5 g/dL
% Patients
72.4
51.7
75.0
50.0
50.0
0.0
60.7
52.4
20.0
2.8
4.1
16.6
4.1
NS
NS
NS
*Acute length of stay refers to acute ward hospitalization. Disposition is
categorized by percentage of patients with a normal albumin level and as a
percentage of the total population
TABLE. Physiologic Changes Associated with Aging*
•Overall Aging Changes
Decreased maximal oxygen consumption (VO2max)
Decreased height
Decreased weight, especially after 74 years of age
•Body Composition
Decreased lean body mass
Decreased intracellular volume
Decreased bone mass
•Cardiovascular
Decreased heart rate; increased stroke volume
Increased systolic blood pressure
TABLE. Physiologic Changes Associated with Aging*
•Lungs
Decreased vital capacity
Increased residual volume
Ventilation-perfusion mismatch leading to decreased po2
Decreased FEV1
•Renal
Decreased creatinine clearance (after 30 years of age)
(8 mL/minute/1.73m2/decade)
Decreased renal blood flow
Decreased maximum urine osmolality
TABLE. Physiologic Changes Associated with Aging*
Hormones
Decreased growth hormone and insulin growth factor
Increased arginine vasopressin and atrial natriuretic peptide
Decreased DHEA (but normal cortisol)
Increased norepinephrine (but normal epinephrine)
Decreased aldosterone and renin
Increased insulin and pancreatic polypeptide
Increased parathormone and decreased calcitonin
Immune System
Decreased T-cell function
Decreased antibody response
*There is a great deal of individual variation, and some healthy older
persons may be well within the range seen in younger adults.
Effect of Aging on Vitamin and Mineral Status
in Humans
Increased
Unchanged
Decreased
Serum copper
Liver iron (females)
Serum ferritin
Liver iron (males)
Liver folate
Serum vitamin A
Serum carotene
Serum riboflavin
Serum biotin
Serum pantothenate
Leukocyte zinc
Blood vessel copper
Serum and hair zinc
Serum calcium
Skin and aorta silicon
Platelet tocopheral
Serum 1,25-dihydroxyvitamin D
Serum iron
Serum thiamine
Tissue chromium
Serum selenium
Plasma and leukocyte
vitamin C
Tissue vitamin C
Serum vitamin B6
Serum vitamin B12
Total Urinary Nitrogen/Creatinine as a Function of Age
Total Urinary Nitrogen/Creatinine
(unitless)
20
Regression Equation: N/Cr = -11.50 + 0.28 * Age
N=13
F=9.39, R2=.46
P=.01
10
0
50
60
70
Age (years)
80
90
Factors Affecting Nutrition in the
Elderly: Physical
•
•
•
•
•
•
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Dentition
Mobility/functional ability
Taste/smell
Constipation
Medication
Eating habits
Chronic illness
Factors Affecting Nutrition in the
Elderly: Psychological
•
•
•
•
Motivation
Confusion\delirium
Dementia
Depression
Factors Affecting Nutrition in the
Elderly: Social
•
•
•
•
•
•
•
•
Isolation
Eating habits
Housing
Transportation
Education
Confusion\dementia
Family\social support systems
Learned patterns of behavior\roles
Factors Affecting Nutrition in the
Elderly: Economic
•
•
•
•
•
Income
Insurance
Education
Housing
Transportation
FEEDING MODALITIES
•
•
•
Oral
Per Tube
TPN
(total parenteral nutrition)
INDICATIONS FOR ENTERAL
FEEDING
•
•
•
•
•
•
neoplasm
surgery
stroke
Parkinson’s
depression
burns
post radiation
trauma
brain injury
dementia
chronic illness
respirator care
CAVEATS ON ENTERAL TUBES
A.
NASOGASTRIC TUBES
– For short term use
– May be misplaced into lung
– Requires patient cooperation
B.
GASTROSTOMY TUBES
–
–
–
Maximum patient acceptance, comfort
Requires adequate gastric anatomy
Inner bulb and outer flange required to
prevent migration
CAVEATS ON ENTERAL TUBES
C.
JEJUNOSTOMY TUBES
Frequent leakage around tube site
– Requires external fixation device
–
D.
ALL ENTERAL TUBES
– Potential for aspiration of feedings
Legal/Ethical Issues
• Standard of Care
provide adequate nutrition and hydration
unless clinical condition prevents
• Withdrawal of Nutrition
competent patient refuses nutrition
advance directives dictate
Case Presentations
Nutrition
Case 1
•
A healthy 65-year-old woman
requests nutritional health
promotion information
Case 2
• An 85-year-old woman with stasis
ulcers and leg edema.
• BMI 30 kg/m2
• Albumin 2.9 g/dL
(3.5 - 5.5 g/dl)
Case 3
•A 75-year-old man from rural
community admitted to rehabilitation
facility following a hip fracture.
• Albumin 3.4 g/dL (3.5 - 5.5 g/dl)
Case 4
•An 80-year-old socially isolated
woman with BMI of 20 (kg/m2)
Case 5
• A 95-year-old man previously self care,
lived with wife in a small town.
Admitted a week ago following a cardiac
arrest, now in a persistent vegetative
state.
Case 6
•78 year old woman with a history of right sided
paralysis following a stroke two months ago.
•Multiple non-healing sacral and pressure ulcers
•Albumin 1.8 g/dL (3.5 - 5.5 g/dl)