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
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
Case Study
Case Study
• Emily Elder (85 y.o.) was walking with her
neighbor Oliver Older (87 y.o.) to the
Senior Center. On the way Emily slipped
on ice and broke her hip. She was taken
by ambulance to the hospital. You are the
health care provider responsible for
Emily’s care.
What information is needed
to evaluate Emily’s current
nutritional status and determine
how to provide for her nutrition?
Given the following, would you be
concerned about Emily’s nutrition?
Height:
5’6”
(167.6 cm)
Weight:
110#
(50 kg)
Previous Wt 140#
(63.6 kg)
Body Mass Index
17.8 kg/m2
Albumin
3.2 gm/dL
Recent Poor Oral Intake
Geriatric Problems
• What geriatric
problems impact
nutritional
status?
Sensory Changes with Aging
• Decreased sense of smell due to
decreased olfactory cells
• Decreased number of taste buds
– i Loss of sweet and salty
– Less loss of bitter and sour
• Decreased vision
• Hearing loss
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
Weight and Mortality
Potter, et al, 1988
Corrada, et al, 2006
Weight
• Primary Parameter
• Standard Tables
• TRENDS
Weight Loss
Practical Considerations
• 5% in one month
• 7.5% in three months
• 10% in six months
Long Term Care Guidelines
American Healthcare Association
Weight
• Normal Trends in Aging
– Peak Weight at 75 years old
– General Trend of Weight Loss after 75
• Abnormal (Unintentional) Weight Loss
• Depression
• Practical Application
– Nutrient Dense Food
– Foods from Food Guide Pyramid
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.
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
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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–
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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
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
Remember
• Osteoporosis is huge problem!
– Incidence: 33% of women 60-70
66% of women > 80
– Less calcium intake in elderly
– Less bioavailability
– Less exposure to sunlight = less
conversion of inactive to active D
– Supplementation essential
• 1200 to 1500 mg/day
Cholesterol in the Elderly
• Serum cholesterol used to identify
malnutrition in the elderly
• Serum cholesterol below 150 indicative of
malnutrition
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
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
Practice
Problem
“NEW” Information
• What’s “new”
in the “old”?
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
What’s “NEW” in the “Old”?
“Vittles, Vitamins, &
the Vintage Old”
– Stroke
– Bone Disease
– Dementia
– Depression
“Vittles and the Vintage Old”:
Colorectal Cancer
• Antioxidants – Selenium, Lycopene,
Vitamin C and Vitamin E
• Dietary selenium and Vitamins C & E were
significantly protective
• Lycopene not associated with cancer risk
• Selenium, C & E may have a role to play
in lowering risk achieved by dietary means
alone
Nutrition and Cancer, 2006
Melbourne Colorectal Cancer Study
“Vitamins and the Vintage Old”:
Colorectal Cancer
• DNA methylation, synthesis, and repair–
folate, methionine, Vitamins B6 and B12
• Vitamins B6 & B12 were significantly
protective for colorectal cancer
• Folate & methionine were protective for
rectal but not colon; highest level 5 risk
• May have a role to play in
lowering risk; achieved by
dietary means alone
Nutrition and Cancer, 2006
Melbourne Colorectal Cancer Study
“Vittles, Vitamins & the Vintage Old”:
Stroke & Transient Ischemic Attack
• Studied effects of folate, Vitamins B6 and
pyridoxal 5-phosphate (PLP)
• Participants with lowest levels of Vitamin
B12 were at risk of cerebral ischemia
compared with those at the highest levels
• These results not observed for Folate or PLP
• Combined low folate & B12
related to 5 risk
• Homocysteine involved?
Stroke, Nov, 2007
European Prospective Investigation Study
“Vittles, Vitamins & the Vintage Old”:
Depression
• 521 elderly studied for 2-3 years for
evidence of depression
• Folate, Vitamin B12, & homocysteine levels
analyzed initially and at follow-up
• Lower levels of folate & Vitamin B12 and
higher homocysteine levels at baseline were
associated with higher risk of depression
• Vitamin B12 declined & homocysteine
increased with depression
British Journal of Psychiatry, 2008
“Vittles, Vitamins & the Vintage Old”:
Bone Disease
• Homocysteine and B vitamins are linked to
bone quality and osteoporotic fracture
• Elevated homocysteine and lowered B
Vitamin levels may have detrimental effect
on bone health
• Further investigation needed to determine if
supplementation with B vitamins could
reduce fracture rates.
British Journal of Psychiatry, 2008
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
may be able to apply?
Post - Test
• What is one
thing that you
would like to
learn more about?