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NutritionintheElderly

©FoodSolutions2017

Overview

• BackgroundonNutritionintheElderly

• PoorNutritionandHealth

• CausesandConsequencesofUndernutrition

• NutritionalGoalsandManagementofUndernutrition

AimandObjectives

Aim:• Toincreasegeneralknowledgeofnutritionalneedsforthe

elderly

Objectives:• Toidentifycausesofundernutritionintheelderly• Todiscussandidentifynutritionalstrategiestoimproveoral

intakeinelderlypeople

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BackgroundonNutritionintheElderly

• Allelderlypeopleareatriskofundernutrition,regardlessofwhetherobeseorunderweight

• Undernutritionaffects10–44%ofolderAustralians

Researchshowspoornutritionintakemayleadto:• Nutritionaldeficiencies• Weightloss• UndernutritionandMalnutrition

Definitions

Undernutrition: ischaracterisedby weightlossassociatedwithsignificantdepletionoffatstoresandmusclemass.Malnutrition: includes 1) undernutrition resultingfromreducedfoodintake; 2)selectivenutrientdeficiencies and3) imbalancesbecauseofdisproportionateintake,associatedwith adverseeffectsontissue/bodyform(shape,size,composition),functionandclinicaloutcomes.

Useavalidatedscreeningtool eg.MST,MNAtodeterminerisk

PoorNutritionandHealth

• Frailtysyndrome(caninclude3ofthefollowing):– Unintentionalweightloss– Physicalweakness– Exhaustion– Slowgaitspeed/poorphysicalperformance– Lowphysicalactivity

• Musclemassdecreasesduetochangestometabolism• Proteinrequirementsupto25%higherthanforyounger

adults

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PoorNutritionandHealthcontinued

Malnutritionhasadverseclinicaloutcomes• Increasedriskoffalls(OP/bonefractures)• Depression• Lethargy• Pressureinjuriesandpoorwoundhealing• Lossofstrength(reducedmobility/independence)• Increasedchanceofhospitalvisits• Poorimmunesystem(increasedinfectionrisk)• Delayedrecoveryfromillness

CausesofUndernutrition

Q:Whatisthemaincauseofmalnutritionintheelderly?A: Disease- Diabetes- Renaldisease- Cancer- OralandGITractdisorders- Parkinson'sDisease- Dementia

Othercausesofundernutrition

• Decreasedtaste&smell• Earlysatiety• Depression&bereavement• Polypharmacy• Constipation• Poororalhealth&dentition• Dysphagia

• Infections• Pain&Functional

challenges• Unnecessarydiet

restrictions

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Decreasedtasteandsmell

• Tastebudsreduceinnumberfrom245at30yo,to~80by70yo

• Senseoftastecomesfromsmell• Decreaseswithmedications• Pathologicandiatrogeniccauses:

– Diabetes,CRF,Sjogren’ssyndrome,Dementia,Parkinson'sDisease

– CancerandRadiation– Hypothyroidism– Zincdeficiency– Depression– Sinusitis

Strategies• Addcream+sugartomilk• Addherbs,spices,butter• Usecondiments&gravies• Servemealshottoincrease

smell,eg.Roasts,Soup,BBQ• Servefoodthatappealsto

theother4senses– sight,sound,texture

• Reducemetallictastebyusingplasticcutleryforcancerpatients

EarlySatiety

• Oftenaccompaniedwithdecreasedtasteandsmell

• IncreasedlevelsofCCK- gastrohormonecauseearly“fullness”duringmeals

• IncreasedCCKismoremarkedinmalnourishedpopulation

Strategies• Offersmall,nutritionally

densemealsandsnacks• Usemedpasswitha2Cal

supplement• Fortifydietwithbutter,

margarine,oil,cream,milkpowderorgratedcheese

• Offernourishingdrinkseg.milk,juice,smoothies,miloratherthanplainwater

DepressionandBereavement

• Prevalentinelderly• Youngover-eat,elderlyunder-eat• Mostcommoncauseofweightlossin

agedcare• 55-63%undiagnosed• Screenfordementia,anxietyand

depression• Medicationscanimprovedepression

andappetite

Strategies• Encouragesocialeating/

eatingout• Findoutfood/drink

preferencesandofferthese• Allowtochooseownmeal• Makemealtimesrelaxed

andenjoyable• Smallerhighprotein/energy

mealsmoreoften• Seatnexttofriendsin

diningroom• Gentlypromptand

encouragetoeat/drink

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Polypharmacy

• Multiplemedications• Somemedicationsinterferewith

particularnutrients• Average8-9medications/day• Combiningmedicationsmayhaveside

effects• Reviewmedsinfluencingappetite/

nutrition&seekalternativemedicationsoreliminateifpossible

Strategies• Timemedicationssonot

“full”fromtabletsbeforemealsifpossible

• Ifmedicationsneedtobecrushed,trymixingwithyoghurt/custard

• Timeantiemetics beforemealstoreducenausea/vomitingandimproveappetite

Constipation

• Inadequatefibreintake• Inadequatefluids• Medicationseg.Endone• Decreasedactivitylevels• Affectsappetite

– Stomachaches&cramps– Feelingbloated– Feelingsick

Strategies• Ensureadequatefluidsthat

arealsohighincalories• Addafibresupplementsuch

asBenefibre tocereal/juiceorsprinkleonfruit/yoghurt

• Incorporatehighfibrefoodseg.WMbread,AllBran

• Pear/prunejuice,prunesatbreakfast

• Encouragephysicalactivity

OralHealth

• Chewingdifficulties• Soremouth• Problemsmayinclude

– mouthsores,tonguelesions,dentalcaries,gumdisease,illfittingdentures,missingteeth,thrush

• Revieworalhealthandencouragedentalreviews

Strategies• Servesofttexturefoodsand/or

mincedmoistmeat• Checkifcold/hotfoods

increasesensitivity• Trytominimisestringy/hard

foodsthatstickinteeth• IncorporateHEHP“easytoeat”

foodseg.custard,yoghurt,icecream,pudding,mousse,avocado,poachedeggs

• Regularoralcares

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Dysphagia

• Signsandsymptoms

• RefertoaSpeechPathologistforpotentialalterationoftextureorthickeningfluids(riskofaspiration)

• Issueswithdysphagialeadtoreducednutrientintake• Tendencytofatigueduringmeals,mayrequireassistance

Infections

• Commoninelderly:UTIs,chestinfections,skininfections,influenza

• Someinfectionsincreaseenergy(ie.calorie)requirements

• Proteinplaysaroleinassistingimmunityandwoundhealing

• Infectiondecreasesappetite• AntibioticscancauseGIdisturbances

anddiarrhoea

Strategies• Fortifiedfoods,eg fortify

porridge,soup,desserts• Encouragehighcaloriefluids

eg lemonade,juice,cordial• Plaintastingfoodsmaybe

preferred,(eg crackers,mashedpotato,bread,hotchips)butaddbutterorcheesetoboostcalories&protein

PainandFunctionalChallenges

• Painaffectsappetite++• Painwithutensils• PTreferralorreviewofpainmedications

Inabilitytofeedoneself– aremealssetup?cutup?– verbaland/orphysicalpromptingused?– adaptiveeatingdevicesneeded?

• OTreferraltodiscussfunctionalchallenges• Fingerfoodscanbeeasiertomanage

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Unnecessarydietrestrictions

• Unpalatable,reducepleasureofeating• Decreaseoralintake(unintentionalweight

loss&undernutrition)• Shouldnotbeprescribedunlessabsolutely

necessary• Nilbenefittorestrictingfoodgroupsthat

provideessentialnutrition• Canbeself-imposedeg.fearofconstipation,

diarrhoeaetc.• Canbeimposedbyfamily• Liberalisedietifatriskofmalnutrition

DietReview

• Lookat– Currentoralintakeeg.diethx,foodandfluidchart– Reasonfordecreasedintakeeg.dysphagia,constipation,dentalissueetc.

– Nutritionalrequirementseg.aretheyincreased?– Oralintaketomeetnutritionalrequirementsi.e.whatneedstobeaddedfortheindividual?

SuccessfulapproachesinNutritionalCare

ü Utilisemulti-disciplinaryteamü Consultwithresident&familyü Increaseintakeviaanumberofstrategiesü Removedietaryrestrictionsü HighEnergyHighProtein(HEHP)dietü Consideroralsupplementsü Eventuallyrestoreawellbalanceddietandwell

nourishedstate

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HPHEDietisusefulwhen:

• Lowweight• Unintentionalweightlosseseg.>2kgin1/12• Reducedintakeduetopoorappetite• Increasedrequirementse.g.pressureinjuries• Firststepistoimprovedietaryintakevia

familiar/preferredfoodspriortosupplements

HEHPDiet

• Meat,chicken,eggs,fish• Nutsandseeds,including

peanutbutter• Dairyfoods- milk,yoghurt,

custard,cheese• Legumes,tofuandlentils

• Butter,cream,oils,margarine,avocado

• Fullcreamdairy• Desserts• Softdrinks,juice,milkshakes&

smoothies• Snackseg.cake,biscuits,party

pies,cheese&crackers

Supplements

• Usedincombinationwithdiet• Determinewhichtimingisbest- betweenmealsorwith

mealsfortheindividual• Manytypes(powder,liquid,puddings,cookies)• Onetypedoesnotfitall• Commencedbynursingstaff,GP orDietitian• Beawareof“tastefatigue”• Useafoodfirstapproach

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Summary

Bytheendofthissession,haveyouachievedthefollowing…

Increasedgeneralknowledgeofnutritionalneedsfortheelderly?

Identifiedcausesofundernutritionintheelderly?

Identifiednutritionalstrategiestoimproveoralintakeinelderlypeople?

Pleaserefertothequizquestionstoassessyourknowledgefromthiscourse.

References

1. BauerJ,etal.Evidence-BasedRecommendationsforOptimalDietaryProteinIntakeinOlderPeople:APositionPaperfromthePROT-AGEStudyGroup.JAMDA.2013;14:542-59.

2. AmericanDieteticAssociation.PositionoftheAmericanDieteticAssociation:IndividualisedNutritionApproachesforOlderAdultsinHealthCareCommunities.JAmDietAsoc.2010;110:1549-53.

3. FlanaganD,etal.ManagingUndernutritionintheelderly.Preventionisbetterthancure.Aust FamPhysician.2012;41(3):695-99.

4. DietitiansAssociationofAustralia.Evidence-basedpracticeguidelinesforthenutritionalmanagementofmalnutritioninadultpatientsacrossthecontinuumofcare.Nutrition&Dietetics2009;66(3Suppl):S1–4.

5. AustralianandNewZealandSocietyforGeriatricMedicine.Under-nutritionandtheolderperson.Positionstatementno.6.Sydney:ANZSGM,2007.

6. Morgan-JonesP,etal.Don’tgivemeeggsthatbounce.HammondCare Media,2014.