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

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

3. Definition of Terms OLD – usual categorization
Young Old –
Middle Old – 75 – 84
Old Old and older
HETEROGENEOUS POPULATION

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. Guiding Principles
Reduced Nutrient Reserves
Reduced Response to Stress

11. Nutritional Care in Geriatrics
LOW and SLOW
L O N G E R

12. Geriatric Problems
What geriatric problems impact nutritional status?

13. Sensory Changes with Aging

14. Sensory Changes with Aging
Decreased sense of smell due to decreased olfactory cells
Decreased vision
Hearing loss
Tactile loss

15. 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

16. Psycho-Social Changes of Aging

17. 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)

18. 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

19. 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.

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

22. 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

23. Usual Weight Trends Gradual Weight Gain – Middle Age
Epidemiology
Gradual Weight Gain – Middle Age
Peak Weight at 75 years
Gradual Weight Loss
after age 75

24. Unintentional Weight Loss
Weight loss >5% in 30 days
>7.5% in 90 days (three months)
>10% in 180 days (6 months)
Example:
5% # in 154# = 146#
10% 15# in 154# = 139#
Long Term Care Guidelines
American Healthcare Association

25. Identifying Weight Change
Weight History
Change in Clothing Fit
Decrease in Functional Ability
Dietary Intake Records
These methods are readily
accessible and cost effective

26. Impact of Weight Loss Most indicative screening parameter
Greater clinical significance
Less reserve capacity
Difficulty regaining weight
Loss of functional ability

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

28. 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)

29. Strategies: Calories Avoid unnecessary dietary restrictions
Encourage use of nutrient dense foods
Use more frequent meals plus
supplements or snacks

30. Practical Suggestions
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

31. 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

32. 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

33. 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

38. 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

40. 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

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

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

43. 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

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

45. 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

46. Fluids
Which fluid is the best fluid?

47. Fluid:Nutrient Comparison
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
217 cc (80%)
250/13
Fruit Beverage Supplement
191 cc (79%)
300/10

48. Fluids What about caffeine for the elderly person?
Have a balanced approach.
Caffeine naivety.
Journal American College of Nutrition, 2003

49. Swallowing Problems Swallow is difficult or hard to initiate S W
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

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

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

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

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

54. 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

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

56. 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?

57. 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

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

59. 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

60. Pressure Ulcers: Nutrition
Protein: 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

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

63. Robertson’s Rule of 2’s Food Item Amount Dietary Fiber Total
100% Bran cereal or Miller’s Bran
1/2 cup or Tablespoons
grams
Whole Wheat Bread
2 slices
4 grams
Fresh Fruit
2 pieces
Vegetables
2 servings
Total
22-26 grams

64. 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
F l u i ds F l u i ds

66. Geriatric Problems
Principle:
Avoid unnecessary dietary restrictions.

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

68. Osteoporosis High incidence of osteoporosis
33% of women 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
mg/day

69. 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

70. Serum 25-hydroxyvitamin D
<20 ng/mL Deficiency
20-29 ng/mL Insufficiency
30-80 ng/mL Optimal Level
>80 ng/mL Possible Toxicity

71. 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)

72. Prevention & Maintenance
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

73. Treatment of Deficiency
50,000 IU of Vitamin D2 weekly
for 8 weeks
Repeat for another 8 weeks if
25-hydroxyvitamin D <30ng/mL

74. 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.

75. 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

76. Practical Suggestions
Oral Supplementation
Practical Suggestions
Product Acceptance
Taste Fatigue
Supplementation not Meal Replacement

77. Oral Supplements Carbohydrate Powder Protein 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)

78. Oral Supplements 100 kcal/1 oz 6 gm/pkt 10 gm protein 23 kcal/Tbl

79. Vitamin/Mineral Supplements
A daily multivitamin mineral supplement is recommended
Geriatric Vitamins
+ Vitamin C,D,E
+ Vitamin B6
+ Vitamin B12
- Iron

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

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

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

83. Benefits to Increasing Appetite
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

84. 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

85. 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 ??

86. 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

87. “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

88. “Vittles, Vitamins & the Vintage Old”: Macular Degeneration
Mineral
Amount
% DV A
14,320 IU
286 C
235 mg
371 E
200 IU
667
Zinc
348 mg
232
Copper
0.8 mg 40

89. Vitamin A Intake
WARNING
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

90. Stay Tuned !

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

93. Post - Test
What is one “NEW” thing that you have learned that you did not know before?