nutritional issues in older adults ronni chernoff, phd, rd, csg, fada
TRANSCRIPT
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Nutritional Issues in Older Adults
Ronni Chernoff, PhD, RD, CSG, FADA
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Life Expectancy of Selected Populations
0
10
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80
90Japan
Australia
Italy
UK
USA
China
Russia
India
Pakistan
Nigeria
South Africa
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Older adults may seem to have an acceptable
nutritional profile but then may decompensate when faced with a physiologic
crisis
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Challenges in nutrition are associated with:
●Nutritional status at onset of treatment
●Nutritional issues of multiple chronic conditions
●Lack of appropriate assessment standards
● Inadequate or unreliable data
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Challenges in nutrition are associated with:
● Inadequately trained nutrition personnel
●Too few hours allocated for RD consultants
●Lack of staff available to feed residents
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● Caloric intake declines by up to 500 kcal/day between 65 and 85 years
● Older adults do not consume adequate protein, calcium, vitamin D and folic acid
Malnutrition in the elderly
Nutrition Screening Initiative. 2004. www.eatright.org/Public/Files/nutrition(1).pdf
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●Impaired eating● Poor oral health● Side effects of prescription drugs
● Undiagnosed illnesses (dementia, depression)
Malnutrition in the elderly
Nutrition Screening Initiative. 2004. www.eatright.org/Public/Files/nutrition(1).pdf
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Body composition changes will impact on how we assess and recognize
nutritional problems in older adults
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Nutritional Assessment
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To rely only on commonly used measures of nutritional
status may yield a false picture of the nutritional
status of an older adult since so many indicators are
impacted by non-nutritional factors
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Only using the common measures of nutritional
status may mask an underlying loss of reserve
capacity
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Older adults may seem to have an acceptable
nutritional profile but then may decompensate when faced with a physiologic
crisis
![Page 14: Nutritional Issues in Older Adults Ronni Chernoff, PhD, RD, CSG, FADA](https://reader036.vdocuments.mx/reader036/viewer/2022062417/55191e7f5503462f428b4b01/html5/thumbnails/14.jpg)
Just because older adults may appear “well-
nourished” does not mean that they are
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Commonly Used Measures of Nutritional Status
● Anthropometric measures● Laboratory/hematologic measures● Immunological measures● Dietary assessment● Drug profiles● Socioeconomic factors
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Anthropometry will be affected by:
● Loss of height due to vertebral compression, osteopenia
● Body composition changes● Shifts in body compartments● Loss of muscle strength and skin
tone ● Lack of age-appropriate standards
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Anthropometric measures
● Height● Weight● Skinfolds● Circumferences● Strength assessment
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Weight changes (losses or gains) may be related to a
variety of risk factors
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Weight change factors include:● Decrease in activity● Decreased basal metabolic rate● Disease-related anorexia● Disease-related cachexia● Effects of drugs● Changes in eating habits/diet● Increasing disability
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If energy intake does not decline but activity level does, the result is
a gain in weight
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Weight gain factors include:
● Decrease in activity● Decreased basal metabolic
rate● Effects of drugs● Changes in eating habits/diet● Increasing disability
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Weight loss should be slow and steady and easy to
manage
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Lifestyle changes need to be made to sustain effective weight loss in older adults
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Weight loss factors include:
● Disease-related anorexia● Disease-related cachexia● Effects of drugs● Changes in eating habits/diet● Increasing disability
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Some older adults experience an unintended
weight loss
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The goal should be to maintain an acceptable weight before
disability associated with obesity becomes an extraordinary burden
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One of the factors in weight change is hydration
status, fluid shifts, and fluid intake
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Laboratory measures may be affected by age because of:
● Hydration status● Impact of multiple drug use● Chronic disease● Acute illness episodes● Changes in organ function
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Commonly used laboratory measures include:
● Albumin● Transferrin● Prealbumin● Retinol-binding protein● Hemoglobin/hematocrit● Electrolytes● Renal function tests
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Albumin is an indicator of many processes that do not have to do with nutritional
status
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Albumin levels may be affected by:
● Bed rest● Fluid balance● Acute physiologic stress● Chronic inflammatory processes● Dysfunctional protein metabolism
● Advanced liver disease● Congestive heart failure● Nephrotic syndrome● Protein-losing enteropathies
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Transferrin may not be a reliable indicator because:
● Total body iron stores increase with age
● Chronic infection, hepatic, renal diseases, cancer, all impact on serum transferrin
● It is not very specific for nutritional status
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Prealbumin/Retinol-binding protein
● Negative acute phase reactant in response to inflammatory processes
● Declines in liver disease, iron deprivation
● Increases in renal failure and with steroid therapy
● RBP is primarily a carrier protein for vit A
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Drug profile may be affected by:
● Polypharmacy● Drug-drug interactions● Food-drug interactions● Use of OTC nutritional
supplements● Poor reporting of OTC
compounds
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Socioeconomic factors:
● Fixed income limitations● Living arrangements
● With whom● Where
● Cooking facilities● Limitations in ADLs● Purchasing priorities
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For older adults other dimensions should be
evaluated, including oral health and functional ability
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Oral health evaluation in older adults:
● Teeth may be loose or missing● Dentures may not fit● Oral lesions may be present● Taste sensitivity may be impaired● Saliva production may be affected by
drugs or disease● Chewing/swallowing difficulties may
exist
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Functional status is usually evaluated by 2 commonly
used scales
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Activities of Daily Living
● Toileting● Feeding● Dressing● Grooming● Ambulating● Bathing
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Instrumental Activities of Daily Living
● Ability to use phone
● Shopping● Food
preparation● Housekeeping
● Laundry● Ability to
travel● Manages own
medications● Handles
finances
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Nutrition Interventions
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Changes may include dietary patterns, activity levels,
nutrition education, cooking suggestions
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Weight loss is a difficult problem to address
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Approaches to try with anorectic older people may
include dietary modifications, supplements, tube or IV feeding, or medications
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Dietary changes may include adding calories to food products, eg. butter,
milk solids, calorie supplements, other fats or
oils
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Small meals, snacks, shakes, oral
supplements, nighttime enteral infusions,
peripheral parenteral nutrition are all options
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Appetite stimulants and anabolic agents have been investigated but the results
are mixed
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Fluid requirements have become an issue of interest
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Dehydration may be associated with:
● hypotension● elevated body temperature● constipation● nausea/vomiting● mucosal dryness● decreased urinary output● mental confusion
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Fluid intake can be estimated at 30 ml/kg
body weight with a minimum of 1500 ml/day
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Recommendations for 8 glasses of fluid per day
may be an overestimation of fluid needs for older
adults
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Thirst is actually a bigger issue
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Thirst may be impaired because:
● decrease in aortic baroreceptors
● decrease in renal function and osmoreceptors
● voluntary limited intake● brain injuries
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Fluid can be consumed in many forms such as juices,
other beverages, frozen desserts, anything liquid at
room temperature
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Voluntary intake may be compromised for many
reasons
● mild incontinence● inconvenience● decreased thirst sensitivity● dementia
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Sometimes involuntary intake is inadequate too
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Meeting fluid requirements is often an issue in wound
healing protocols
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Tube feedings are made of solids dispersed in liquid and
approximately 25% of TF volume needs to be added as free water to actually meet
fluid needs
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In addition to changes in overall energy and fluid needs, requirements for other essential nutrients
change too
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Nutrient Requirements
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Nutrient requirements may change with age due to
physiological, health status, body composition, and activity level changes
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Key nutrient requirement changes:
● Protein● Vitamin B12● Vitamin A● Vitamin D● Calcium● Energy related to decreased
activity level
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Protein requirements are affected by:
● decrease in total LBM
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Protein requirements are affected by:
● decrease in total LBM● loss of efficiency in protein
turnover
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Protein requirements are affected by:
● decrease in total LBM● loss of efficiency in protein
turnover● increased need to heal
wounds, surgical incisions, repair ulcers, make new bone
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Protein requirements are affected by:
● decrease in total LBM● loss of efficiency in protein
turnover● increased need to heal
wounds, surgical incisions, repair ulcers, make new bone
● infection
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Protein requirements are affected by:
● decrease in total LBM● loss of efficiency in protein
turnover● increased need to heal wounds,
surgical incisions, repair ulcers, make new bone
● infection● immobilization
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RDA for adults is 0.8 g/kg/body weightFor older adults,
requirements are for 1.0 g/kg/body weight or more
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Studies by Gersovitz, in early 80s, and Campbell et al in late 90s and early 2000+ support the need for 1 or more g/protein/kg body
weight
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Vitamin B12
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Assuring adequate vitamin B12 is a challenging goal
throughout the life cycle but particularly in older adults
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Vitamin B12
● Is primarily available in animal protein sources
● Has a complex transfer and absorption pattern
● Has a vague presentation of deficiency
● May be associated with a decline in cognitive function
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Vitamin A
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Vitamin A requirements are altered by age due to
alterations in hepatic vitamin A metabolism
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Vitamin A is needed for cell differentiation
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Cell differentiation processes allow for the
development of different tissues
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There has been discussion about
lowering recommendations for
preformed vitamin A in older adults
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Vitamin A requirements in wound healing should not exceed 200% of the RDA
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Beta carotene does not have any negative side effects
other than its accumulation in serum, potentially causing
discolored epidermis
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Beta carotene seems to have a protective effect for
epidermal tissue cancers
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Vitamin D
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Vitamin D is a nutrient that older adults are at risk for
deficiency
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Risk factors for vitamin D deficiency
● inadequate dietary intake● inadequate sunlight exposure● decreased synthesis in skin (7-
dehydrocholesterol)● diminished renal function –
reduced hydroxylation
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Vitamin D is essential to manage:
● Falls and fractures prevention
● Osteoporosis and dentition● Cognition● Immune function● Blood pressure● Colon cancer (?)
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Energy Needs
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To maintain weight, 20-25 kcals/kg body weight is usually adequate in a
relatively sedentary adult
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For stress, wound healing, infection, fracture, energy needs may increase to as much as 35 kcals/kg body
weight
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Energy needs decline with a reduction in metabolically
active cell mass: protein and bone
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Energy needs increase with demands for wound healing,
fracture repair, infection response
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To avoid or heal wounds of any type, nutrient needs must be met to support
homeostasis
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Key nutrients needed for wound healing
● Protein● Energy● Vitamin A● Vitamin C● Zinc
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Protein Needs
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Protein needs may be as high as 2+ g/kg body weight
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Albumin levels may be affected by:
● Bed rest● Fluid balance● Acute physiologic stress● Chronic inflammatory
processes● Dysfunctional protein
metabolism
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Albumin levels may be affected by:
● Dysfunctional protein metabolism
● Advanced liver disease● Congestive heart failure● Nephrotic syndrome● Protein-losing enteropathies
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Vitamin C
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Vitamin C
● Status is related to dietary intake
● Institutionalization, hospitalization and illness lead to sharp decreases in vitamin C intake
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Vitamin C
● Decreases seen with chronic disease including atherosclerosis, cancer, senile cataracts, lung diseases, cognition, and organ degenerative diseases
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● Vitamin C is easily replaced● Smokers may need 2x RDA just
to meet requirements
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● Vitamin C is important in wound healing because of its role in hydroxylation but tissue saturation is achieved easily and large doses are excreted in urine
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Zinc
● Most older adults are not zinc deficient
● Increased levels may be needed for wound healing but do not have to be very high (225mg/day in divided doses)
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Zinc
● Large amounts of zinc interfere with absorption of other divalent ions
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Copper, iron, magnesium, manganese may be affected
by large doses of zinc
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Getting old in America is challenging but nutritional
challenges can be managed with creativity and ingenuity
and patience