2. Nutrition and the Elderly Sandra Stork MS, RD, LMNT

3. Nutrition and the Elderly Why study nutrition and the elderly?

4. Definition of Terms OLD – usual categorization –Young Old – 65 – 74 –Middle Old – 75 – 84 –Old Old – 85 and older

5. IQ Pre-Test IQ = Inquiry Quotient Test your knowledge and stimulate your interest and inquiry.

7. Topics Changes of Aging Related to Nutrition Geriatric Problems What’s “new” in the “old”?

8. 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.

9. Objectives Identify the association between selected Geriatric Problems and nutrition: –Sarcopenia-Weight Loss –Dehydration-Swallowing –Dementia-Pressure Ulcers –Constipation-Depression Develop strategies for the treatment of these problems.

10. Reduced Nutrient Reserves Reduced Response to Stress

11. Nutritional Care in Geriatrics

12. Case Study

13. 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.

14. What information is needed to evaluate Emily’s current nutritional status and determine how to provide for her nutrition?

15. Given the following, would you be concerned about Emily’s nutrition? Height:5’6”(167.6 cm) Weight:110#(50 kg) Previous Wt140#(63.6 kg) Body Mass Index17.8 kg/m2 Albumin3.2 gm/dL Recent Poor Oral Intake

16. Geriatric Problems What geriatric problems impact nutritional status?

18. Sensory Changes with Aging Decreased sense of smell due to decreased olfactory cells Decreased number of taste buds –  Loss of sweet and salty – Less loss of bitter and sour Decreased vision Hearing loss

20. 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)

21. 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

22. 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.

24. Geriatric Problems Weight Loss Sarcopenia Dehydration Swallowing Dementia Pressure Ulcers Constipation Depression

25. Weight and Mortality Potter, et al, 1988 Corrada, et al, 2006

26. Weight Primary Parameter Standard Tables TRENDS

27. Weight Loss Practical Considerations 5% in one month 7.5% in three months 10% in six months Long Term Care Guidelines American Healthcare Association

28. 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

29. 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

33. 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

35. 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

36. Protien Add nonfat dried milk solids Add cheese, peanut butter, eggs and nuts (if dentition permits) Use commercial protein powders or supplements Practical Suggestions

37. Geriatric Problems Weight Loss Sarcopenia Dehydration Swallowing Dementia Pressure Ulcers Constipation Depression

38. Dehydration: Causes 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

39. Dehydration: Symptoms Decreased Skin Turgor Dry Mouth and Mucosal Membranes Decreased Urine Volume Darker Urine Constipation Acute Weight Loss CONFUSION

40. Dehydration Practical Application 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

41. Fluids Which fluid is the best fluid?

42. Fluid:Nutrient Comparison FluidFree Water (cc)Calories/Protein Water240 cc (100%) 0/0 Juice (Apple)210 cc (88%) 111/0 Whole Milk214 cc (89%) 150/8 Instant Breakfast 217 cc (80%) 250/13 Fruit Beverage Supplement 191 cc (79%) 300/10

43. Fluids What about caffeine for the elderly person? Have a balanced approach. Caffeine naivety.

44. Swallowing Problems SWALLOWING SWALLOWING Swallow is difficult or hard to initiate Wet sounding voice Aspiration pneumonia in history Loss of fluid through the nose Leakage of food or liquid out of mouth when eating Overt coughing or choking with oral intake Weight loss with inadequate nutritional intake Involve Speech Pathologist and others Nutrient Density Go for Least Restrictive

45. Swallowing Practical Application Be Alert to Symptoms Consult Speech Pathologist Involve Dietitian/Nutrition Fluid and Nutrient Density

46. Geriatric Problems Weight Loss Sarcopenia Dehydration Swallowing Dementia Pressure Ulcers Constipation Depresssion

47. Dementia Weight Loss Primary Nutritional Problem Stage of Disease Important Eating Behaviors

48. Eating Behaviors: Overview Eating is NOT just food Barometer of well being Social interaction Symbolic of life

49. Eating Behaviors: Examples 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

50. Principles of Management Assess problems Utilize creative strategies to address individual problems Think OUT OF THE BOX Alternate strategies Continue reassessment process Multidisciplinary approach

51. Eating Behaviors: Questions? What is being said by behaviors? Are behaviors harmful? What precipitated the behaviors? Is there an unmet need? What are potential causes?

52. Eating Behaviors: Strategies 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

53. Geriatric Problems Weight Loss Sarcopenia Dehydration Swallowing Dementia Pressure Ulcers Constipation Depresssion

54. Pressure Ulcers Screening Tool: (Example – Braden Scale) –Sensory Perception –Moisture –Activity –Mobility –Friction and Sheer –Nutrition Cooperation and Collaboration Needed –Nutrition is only one component

55. 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

56. Geriatric Problems Weight Loss Sarcopenia Dehydration Swallowing Dementia Pressure Ulcers Constipation Depression

59. Food ItemAmountDietary Fiber 100% Bran cereal or Miller’s Bran 1/2 cup or 2 Tablespoons 10-14 grams Whole Wheat Bread 2 slices 4 grams Fresh Fruit2 pieces 4 grams Vegetables2 servings 4 grams Total22-26 grams Robertson’s Rule of 2’s

62. Geriatric Problems Principle: Avoid unnecessary dietary restrictions.

63. Nutrients of Concern in the Elderly Calories –Nutrient Density Protein Calcium Vitamin D Supplements? Don’t forget –Fiber –Fluids

64. 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

65. Cholesterol in the Elderly Serum cholesterol used to identify malnutrition in the elderly Serum cholesterol below 150 indicative of malnutrition

66. 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

67. Macular Degeneration Vitamin/ Mineral Amount% DV A14,320 IU286 C235 mg371 E200 IU667 Zinc348 mg232 Copper0.8 mg40

68. WARNING

69. 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 pre- curser form which does not increase fracture

71. Practice Problem

72. “NEW” Information What’s “new” in the “old”?

73. Appetite Stimulation Sensory Changes with Aging Decreased sense of smell due to decreased olfactory cells Decreased number of taste buds Decreased vision

74. 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

75. 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

76. 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 ??

77. 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

78. What’s “NEW” in the “Old”? “Vittles, Vitamins, & the Vintage Old” –Stroke –Bone Disease –Dementia –Depression

79. “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

80. “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  risk May have a role to play in lowering risk; achieved by dietary means alone Nutrition and Cancer, 2006 Melbourne Colorectal Cancer Study

81. “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  risk Homocysteine involved? Stroke, Nov, 2007 European Prospective Investigation Study

82. “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

83. “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

86. Topics Changes of Aging Related to Nutrition Geriatric Problems What’s “new” in the “old”?

87. Post - Test What is one “NEW” thing that you have learned that you may be able to apply?

88. Post - Test What is one thing that you would like to learn more about?