1. Undernutrition in the old age-costs and treatment implications
Danit R Shahar, RD, PhD

2. Danit R Shahar, RD, PhD The S
Danit R Shahar, RD, PhD The S. Daniel Abraham International Center for health and Nutrition Ben-Gurion University-Israel
Clinical dietitian
PhD in nutrition epidemiology
PhD Thesis: Factors associated with dietary intake and eating habits of community dwelling elderly people living in Pittsburgh, USA
Areas of interest:
Dietary assessment methods
Factors associated with undernutrition among the elderly

3. Personal Statement
My professional commitment is to study and develop research programs and teach students of all health disciplines the topic of geriatric nutrition.
The work may create these people as leaders in their communities and thus change people views and attitudes toward older people.

4. Learning objectives:
To understand the concept of undernutrition among the elderly population
To understand the implications of undernutrition in terms of health consequences, cost and treatment
To be familiar with the main risk factors and causes for nutritional deterioration and deficiencies
To understand the basic concepts of dietary assessment of the elderly population

5. Nutritional status of the elderly population-the prevalence of undernutrition
COMMUNITY SURVEYS:
35-40% < 2/3 RDA calories (Bidlack 1992)
70--78%< RNI* calories (Payette, 1995)
48-60% < RNI* Protein (Payette, 1995)
NURSING HOME SURVEYS:
5-18% < RDA calories (Rudman, 1989)
0-33% < RDA protein (Rudman, 1989)
*RDA=Recommended Dietary Allowances
**RNI=Recommended Nutrient Intake-Canadian recommendations-Different approach than the RDA

6. Calories 16%-18% 20%-30% 25%-40% Riboflavin 6%-36% 7%-13% 15%-20%
Nutrient NHANES I NHANES II NHANES III
( ) ( ) ( )
Calories 16%-18% 20%-30% 25%-40%
Riboflavin 6%-36% 7%-13% 15%-20%
Vitamin B6 50%-90% 54%-69% 25%-50%
Vitamin A 42%-65% 22%-36% 25%-30%
Vitamin C 23%-58% 22%-31% 15%-25%
Calcium 40%-50% 30%-43% 25%-50%
Table I:Percentage of inadequate intake of nutrients
based on NHANES I II and III data
(The NHANES III data is based on NCHS/CDC)

7. Dietary intake as compared with the DRI: (Negev Nutrition Study):

8. Do we treat undernutrition?
McWhirter & Pennington BMJ, Only 2% of undernourished hospitalized patients are being treated. 5% were referred to treatment during their hospitalization..
During hospitalization 64% of the patients have lost weight.
70% showed improvement in their nutritional status after treatment.

9. General consequesnces of undernutrition:
Weight loss is associated with a decline in function ability (Allison, 1992)
Delayed wound healing (Hill, 1992)
Impairment of the immune system which may increase the risk and consequences of infection (Chandra, 1988)
With severe weight loss, both cardiovascular and gastrointestinal functions are impaired
Malnourished people may become depressed and apathetic (Brozek, 1990)

10. General consequesnces of undernutrition II:
Loss of muscle strength (Lesourd BM, 1995)
Increase in fractures
Increased incidence of pressure sores
Specific micronutrient deficiencies

11. Malnutrition and post-surgical complications (Meguid, 88)

12. Cost of a stay in hospital in malnourished and well nourished patients with or without major complications (Reilly, 88)
Cost of average hospital stay
$12,683
Malnourished pt. with major complications (n=67)
$7,375
Normally nourished pt. With major complications (n=20)
$3,469
Malnourished pt. With no complications (n=312)
$2,968
Normally nourished pt. With no complications (n=304)

13. Energy balance: Naturally there is a decrease in energy needs.
Till 70 years old there is a positive energy balance associated with weight gain
After age 70 we can see a negative balance associated with weight loss. Lean body mass and body fat tend to be reduced (Morley)
Weight loss in the older age is associated with increased mortality and morbidity

14. Weight, weight change, and mortality in a random sample of older community-dwelling women -JAGS 47:
White older community-dwellers women are at increased risk of mortality
if they are underweight, lose weight or weight cycle

15. RR for mortality according to BMI among older people 70 years and older: AJCN 2001 55(6):482-492

16. Risk facrots for undernutrition
Physiological factors:
Impaired senses of smell/taste
Dental problems
Decreased gastric acid secretion
Medication/Medical problems
Decreased mobility affecting purchase and preparation of foods

17. Drug therapy in the old age - Nutritional aspects
Multiple medication due to co-morbidities
Effect of medications on digestion and absorption
Direct effect of medications on appetite
Medication may decrease or distort taste and smell
Certain medication may cause oral dryness
Certain medication may decrease mobility of the stomach and gastrointestinal tract
Diarrhea and decreased absorption (antibiotics)
Behavioral aspects
Changes of nutritional needs (diuretics)

18. Medication and appetite:
Increase appetite and food intake
Steroids
Sex hormones
Antipsychotic
Antihistamin
Prokinetic
Kanavis
Decrease appetite and food intake
Sympathomimetics
Anti-parkinsonian [L-dopa, Sinemet]
Antidepressants, SSRI, Prozac and realted Rx
Xantines [Theophylline]
Digitalis

19. RISK FACTORS FOR MALNUTRITION: (cont)
Socioeconomic factors:
Declining income and retirement
Smaller household size
Loss of spouse
Isolation and institutionalization
Psychological factors:
Depression
Stressful life events
mental confusion

20. Click for larger picture
Eating habits and caloric intake – NNS results: Decreased appetite, low snacking, gastrointestinal problems and poor health status were associated with low caloric intake
Click for larger picture ** ** ** *

21. Other risk factors for undernutrition among the elderly population:
Eating less than needed-fewer products and smaller meals or portions
Decreased appetite and early satiety
Changes in energy regulation
Changes in the levels and function of neuropeptides (NO decrease, CCK increase>>>early satiation)
Decreased enjoyment of eating

22. What patients are at risk for nutritional deterioration?
Cancer
Cardiovascular Heart Failure
Chronic Obstructive Pulmonary Disease (COPD)
Post-surgery
Gastrointestinal diseases
Liver Cirrhosis
Renal Failure
Depression
Dementia
These diseases may be hypermetabolic and / or induce anorexia

23. What are the most typical nutritional deficiencies in the old?
Vitamin B12 (Usually not dietary)
Folic acid
Vitamin B6
Antioxidants vitamins
Zinc
Vitamin D
Calcium
Vitamin K

24. Factors associated with nutritional deficiencies
Eating lower nutritional quality foods such as bread and butter exclusively
General and specific deficiencies due to higher needs, co-morbidity and multiple medications.
Physiological and pathophysiological changes in the gastrointestinal system impact the ingestion and digestion of nutrients
Unnecessarily restrictive diets

25. General deterioration “I am not important to anyone”
Risk factors:
Psychological
Physiological
Socioeconomic
Loss of motivation/will to eat
General deterioration
“I am not important to anyone”
Nutritional
deficiencies
Eat small amounts

26. Intervention strategies:
Treatment of risk factors
Better
eating
Regaining physical and emotional strength
Quality of life improve

27. Weight as a key measurement for nutritional status
Weight history is one of the simplest and most consistent measure (Mobarahan 1991)
Weight change is a key variable in nutrition assessment in the elderly (Jeejeebhoy 1991)
Recent weight loss is a sensitive indication of individuals at nutritional risk (Fogt 1995)

28. Weight loss as an indication of nutritional deterioration
An involuntary weight loss of 10% of more especially over a short period of time
weight loss of 1 kg per week, 2 per month.
Weight loss trend over time

29. Nutritional assessment:
Assessment of appetite
Are all food groups included in each meal (5 colors of food per meal)
Enjoyment of eating
Use of Mini Nutritional Assessment (MNA) or eating behavior questionnaires
Biochemical and clinical assessment

30. Recommendations: Dietary assessment as part of geriatric assessment
Healthy eating
Encourage Snacking
High quality drinks or supplements (shakes)
Caution with prescribed “medical” diets
Judicious use of medication
Treating risk factors (depression)
Fortified foods
Supplements [energy!!! + nutrients]
Encourage weight stability, avoid loss!!!