Undernutrition in the old age-costs and treatment implications

Danit R Shahar, RD, PhD

Danit R Shahar, RD, PhDThe S. Daniel Abraham International Center

for health and NutritionBen-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

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.

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

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

Nutrient NHANES I NHANES II NHANES III (1971-74) (1976-80) (1988-91)

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)

0

20

40

60

80

100

120

Percent of the DRI

Selected nutrientsMenWomen

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

Do we treat undernutrition?

McWhirter & Pennington BMJ, 1994 -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.

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)

General consequesnces of undernutrition II:

Loss of muscle strength (Lesourd BM, 1995)Increase in fractures Increased incidence of pressure sores Specific micronutrient deficiencies

Malnutrition and post-surgical complications (Meguid, 88)

29

72

4

23

0

10

20

30

40

50

60

70

80

Complication rate Post-operativemortality

Well nourishedMalnourished

P<0.001

P<0.001

Cost of a stay in hospital in malnourished and well nourished patients with or

without major complications (Reilly, 88)

Cost of average hospital stay

Malnourished pt. with major complications (n=67)

$12,683

Normally nourished pt. With major complications (n=20)

$7,375

Malnourished pt. With no complications (n=312)

$3,469

Normally nourished pt. With no complications (n=304)

$2,968

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

Weight, weight change, and mortality in a random sample of older community-dwelling women -JAGS 47: 1409-1414

0

5

10

15

20

25

30

%

Loss No Change Gain Cycle

Weight change categories

LowAverageHighTotal

White older community-dwellers women are at increased risk of mortality

if they are underweight, lose weight or weight cycle

RR for mortality according to BMI among older people 70 years and older:

AJCN 2001 55(6):482-492

0,6

0,8

1

1,2

1,4

1,6

1,8

RR Males

Females

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

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)

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

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

Caloric intake by risk factors and gender

0200400600800

100012001400160018002000

Known risk factors for decreased dietary intake

Me

an

ca

lori

c i

nta

ke

men-yes

men-no

women-yes

women-no

** ** **

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

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

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 DementiaThese diseases may be hypermetabolic and / or induce

anorexia

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

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

PhysiologicalSocioeconomicPsychological

Ris

k fa

cto

rs:

Loss of motivation/will to eat

General deterioration“I am not important to anyone”

Nutritional deficiencies

Eat small amounts

Intervention strategies:

Treatment of risk factors

Regaining physical and emotional strength

Quality of life improve

Better eating

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)

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

Nutritional assessment:

Assessment of appetiteAre all food groups included in each meal

(5 colors of food per meal)Enjoyment of eatingUse of Mini Nutritional Assessment

(MNA) or eating behavior questionnairesBiochemical and clinical assessment

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!!!