NUTRITION AND THE ELDERLY

            

YAAKOV LEVINSON, MS, NUTRITIONIST

The elderly are at high risk for poor nutritional status (1).  Malnourished and nutritionally deficient elderly people are seen daily in clinics and hospitals.  Malnutrition and undernutrition probably are responsible or at least significantly contribute to many of the non-specific symptoms observed in elderly persons such as mental confusion, chronic fatigue, a general feeling of ill-health, and loss of appetite (2).  All of these symptoms may eventually lead to even more pronounced malnutrition.

It has been reported that protein-calorie malnutrition is common in the institutionalized elderly (3).  One can only imagine how much malnutrition actually exists among the general geriatric population undetected by scientific studies!   Protein-calorie malnutrition is the most severe and important nutritional problem of the elderly (4,5). Many other nutritional deficiencies may occur simultaneously or independently as will soon be discussed.  The most frequent complication of nutritional deficiency in these persons is an acute infection which may lower the older person’s quality of life or may even become life-threatening (6).

Malnutrition in the elderly is brought about by changes in economic circumstances and way of life which often occur in the elderly and retired, and by the increasing incidence of illness and disability leading to an alteration in dietary intake, absorption, and metabolism of nutrients.

The high-risk status of the elderly for low intakes of nutrients is due to many factors which will be listed and discussed at length.

 

FACTORS LEADING TO DIETARY DEFICIENCY IN THE ELDERLY

1. Physical and mental disabilities (limited mobility)

2. Psychosocial changes (social isolation and apathy)

3. Fixed income (poverty)

4. Medical conditions

5. The decline of body functions

6. Medications (alcoholism)

7. Oral status

8. Susceptibility to fads

9. Ignorance

10. Iatrogenic causes

 

1. PHYSICAL AND MENTAL DISABILITIES (limited mobility)

A serious and continuous effort must exist to maintain or to increase physical movement and activity in elderly men and women.  The amount of physical activity in the elderly is probably the most critical factor in affecting nutritional status (7). When physical activity decreases, energy expenditure also lessens, and the appetite deteriorates.  The amount of food eaten becomes less. Together with the reduced food requirement associated with being elderly, this further decrease of food intake may result in deficiencies of several nutrients. Decreased nutritional status over time would normally result in pathological deterioration.

Physical disabilities might include such conditions as arthritis, cataracts, poor eyesight, Parkinson’s disease, paralysis, swallowing difficulty (8) (dysphagia), or fractures.  Such disabilities will limit activity and mobility of the elderly person and will inhibit shopping, cooking, and eating activities. Dysphagia would put them at risk for inadequate food and fluid intake since they may be fearful of choking and may resist eating.  Such persons require trained supervision at meals. Elderly persons often require feeding assistance and no one is available to help them cut meat or open food packages.

Mental disorders such as confused state, paranoia, dementia, depression, and a desire to die will inhibit normal food intake and will cause forgetfulness in preparing and eating food (9).

 

2. PSYCHOSOCIAL CHANGES (Social Isolation and Apathy)

Changes in life situations such as loss of a marital partner or retirement may produce social isolation leading to loneliness and depression with subsequently reduced appetite and lack of motivation to buy food, cook, and eat.  Apathy toward food may limit nutritional selection to easily prepared foods. Such a narrow diet selection may result in nutritional difficulties if it persists (10,11)

3. FIXED INCOMES (Poverty)

Lowered incomes will limit food selection to the cheaper carbohydrate foods as opposed to the expensive foods rich in protein, vitamins, and minerals (12).  Starchy foods will provide a feeling of satiety at a low cost. The elderly living on low-cost diets with little animal protein seem particularly vulnerable to the development of nutritional anemias.

A combination of nutritional anemias may coexist in elderly persons, most often consisting of iron-deficiency anemia and deficiencies of either folic acid or vitamin B-12 or both. Folic acid deficiency may also occur together with a deficiency of vitamin C, since both of these vitamins are found in fresh fruits and vegetables which are often reduced in the diets of the elderly.

 

4. MEDICAL CONDITIONS

Conditions such as abdominal pain, gastric distension, diarrhea, or nausea, will affect food intake and nutrient absorption.  Other conditions such as heart disease, diabetes, digestive problems, fractures, major surgery, or illness may require dietary modification with food restrictions.  No sugar, no salt, low fat, or no spice diets may be tasteless or unpalatable if improperly prepared.

 

5. DECLINE OF BODY FUNCTIONS

With aging, there are changes (13) in the gastric mucosal lining, development of achlorhydria (reduced stomach acid), and possible decreases in the production of intrinsic factor which results in poor absorption of vitamin B-12.  Pernicious anemia resulting from a B-12 deficiency is specifically a disease of old age. Iron absorption is also impaired in the elderly and together with diets low in iron characteristic of most elderly persons makes iron deficiency anemia a common disorder.

Elderly persons may, as well, develop reductions in levels of digestive enzymes and lactose intolerance due to deficiency of the intestinal lactase enzyme thereby preventing the digestion and absorption of milk sugar, lactose.  This condition results in bloating, discomfort, gas, and diarrhea following ingestion of dairy products. Susceptible persons generally learn to avoid this important group of foods. Over time such practices will lead to dietary calcium deficiency which may result in or enhance the development of osteoporosis, a disease marked by severe brittleness or fracturing of the bones.

Motility of the gastrointestinal tract also decreases with age.  The esophagus may suffer a variety of age-related conditions that influence eating such as diverticula, spasm, and hiatal hernia.  As well, relaxation of the lower esophageal sphincter, delay of esophageal emptying, and increase in non-propulsive contractions may occur.  Slower emptying of the stomach may result in loss of appetite (anorexia).

Mild degrees of malabsorption are not uncommon in the elderly with a resulting decrease in absorption of nutrients such as fat and fat-soluble vitamins (A, D, E and K), folic acid, and vitamin B-12.  There may be a distortion of taste or smell leading to reduced appetite.  As well, the time needed for an elderly person to regain his appetite following illness is generally longer than in a young person.

On the other hand, food habits of the elderly may continue unchanged.  The decreased energy need and expenditure of age is not always followed by a decreased caloric intake.  This practice may result in varying degrees of obesity.

 

6. MEDICATIONS (Alcoholism)

Medications may affect the nutritional status of the elderly in a primary manner by decreasing the absorption and metabolism of nutrients.  As well, they may interfere with appetite and may have secondary effects causing nausea, vomiting and diarrhea (14). Multiple drug treatments common among the elderly puts this group at risk for drug-induced nutrient deficiencies (15).  Drugs may alter taste sensations, limit salivary secretion, suppress or stimulate appetite, alter the sense of smell, cause stomach irritation, alter gastrointestinal motility, cause internal bleeding leading to anemia, interfere with vitamin metabolism, or deplete the body’s mineral stores.

 

7. ORAL STATUS

Changes such as worn, lost, or poorly fitting dentures may influence food choices or eating ability, as may dental or periodontal disease or reduced taste acuity (16).  In these situations, meat and vegetables are often avoided, and carbohydrate foods requiring little chewing are substituted.

 

8.SUSCEPTIBILITY TO FADS

Health tonics or vitamin mixtures are sold to the elderly promised as remedies for all sorts of ills and pains.  As well, the elderly read and believe fad health books promoting non-experimentally based claims (17). All of these may cost the older person money which could be more appropriately used to purchase a better- quality diet.  Food faddists may encourage the elderly person to avoid seeking qualified medical care when truly indicated.

 

9. IGNORANCE

Elderly persons were often raised in times of hardship where lack of money determined their dietary choices and formed their knowledge of nutrition.

Ignorance about basic nutrition and meal planning is most common amongst elderly men, who for the first time must fend for themselves when widowed.

 

10. IATROGENIC CAUSES

Special diets medically prescribed when indicated for one or more chronic illnesses continued for longer than necessary periods of time may lead to malnutrition (18).  Restrictions in diet due to advice from well-meaning friends, information from advertising or from magazine articles, when followed may also have a detrimental effect on nutritional intakes and on general health.

Keeping these risk factors clearly in mind should help us prevent many of the nutritional problems that can afflict the elderly.

 

In short, the challenge facing us is that the food habits and the food intake of the elderly do not always coincide with their food needs.  In these cases, therefore, the elderly persons involved will be at high risk or will already appear in poor nutritional condition. Proper nutritional care, on the other hand, can prevent future complications, and can generally improve the level of health in the elderly.

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A SIMPLE GUIDE TO ASSESSING MALNUTRITION IN PRIMARY CARE OF THE ELDERLY

The aging population of the developed world has increased including a significant increase in the number of elderly with malnutrition.  Many of these patients are seen in the community by primary care physicians and paramedical personnel. Assessment and detection of malnutrition in these patients require time and skills which are often lacking in the primary care situation.  This may commonly lead to a lack of awareness, diagnosis and treatment of elder persons with impaired nutritional status. We shall, therefore, present a structured, simple approach to the assessment of geriatric malnutrition for the primary care physician and paramedical professional.  We stress the importance of referring high-risk patients to a professional dietitian/nutritionist for further more detailed assessment and treatment, whenever possible.

 

DEFINITION OF MALNUTRITION IN THE ELDERLY

The Dutch Guideline Screening and Treatment of Malnutrition (19) defines malnutrition as “an acute or chronic condition where a deficiency or in-balance of energy, protein and other nutrients cause measurable and adverse effects on body composition, function and clinical outcomes”.

Malnutrition has severe effects on the health of a geriatric patient, such as decreased recovery from illness and impaired immune function, increased risk of developing pressure sores, physical and mental degeneration, prolonged hospitalization, increased need for home care, nursing home admission, falls, decreased weight and muscle mass, increased mortality, decreased quality of life, and greater risk of social isolation.  Therefore, early recognition of these high-risk patients is essential in order to prevent the complications of malnutrition.

 

SCREENING TOOLS FOR ASSESSMENT OF GERIATRIC MALNUTRITION

There have been many screening tools for the assessment of geriatric malnutrition.  Such tools include the MNA (Mini Nutritional Assessment) (20), Geriatric Nutritional Risk Index (21), MUST (Malnutrition Universal Screening Tool) (22), and the NSI (Nutrition Screening Initiative) Scales Assessment Malnutrition Scale (23).

The European Society of Parenteral and Enteral Nutrition (ESPEN) guidelines recommend using the Mini Nutritional Assessment (MNA) to detect undernourished elderly at home or in a nursing home setting (24).  For hospitalized adults of all ages, the ESPEN guidelines recommend using a combination of body mass index (BMI in kg/m2) and weight loss (MUST, Malnutrition Universal Screening Tool).

The MNA (Mini Nutritional Assessment) is considered the Gold standard in nutritional screening for the older adult.  It consists of simple measurements and six brief questions that can be completed in about five minutes. The MNI was designed and validated (25) to provide a fast assessment of the nutritional status of frail elderly in order to promote nutritional intervention.  The MNA Short Form requires no blood tests, and it is available in twenty-seven languages: Bengali, Chinese, Czech, Dutch, English, Farsi, Finnish, French, German, Greek, Hindi, Indonesian, Italian, Japanese, Korean, Lithuanian, Norwegian, Portuguese, Polish, Romanian, Sinhala, Slovakian, Spanish, Turkish, Thai and Urdu.  Translation to other languages is expected.

The MNA-SF (Mini Nutritional Assessment Short Form), the preferred form of the MNA for clinical use in primary care, is a nutrition screening tool.  It is not meant as a substitute for a complete nutritional assessment by a qualified nutrition professional. It is intended for quickly identifying older adults who are malnourished or at risk for malnutrition.

The MNA may be incorporated into the electronic health record on the condition that users comply with copyright and trademarked requirements.  (contact info@MNA 24. Com for more information). MNA – S: phone is available , Phone Application is available free (English, French) from the iTunes store.  The MNA application can be used on an iPad.

 

MINI NUTRITIONAL ASSESSMENT

MNA

 

Last name:_____________________________________ First Name:____________________________________

Sex:_______  Age: _______  Weight, kg:________  Height, cm:_______ Date:_______________

Fill in the appropriate numbers.

Total numbers for the final screening score.

 

(A) Has food intake declined over the past 3 months due to loss of appetite, digestive problems, chewing or swallowing difficulties?

0=severe decrease in food intake

1=moderate decrease in food intake

2=no decrease in food intake ………

 

(B) Weight loss during the last 3 months

0=weight loss greater than 3 kg (6.6 pounds)

1=does not know

2=weight loss between 1 and 3 kg (2.2 -6.6 pounds)

3=no weight loss ………

 

(C) Mobility

0=bed or chair bound

1=able to get out of bed/chair but does not go out

2=goes out……….

 

(D) Has suffered psychological stress or acute disease in the past 3 months?

0=yes   

2=no ……….

 

(E)  Neuropsychological problems

0=severe dementia or depression

1=mild dementia

2=no psychological problems ……….

 

(F) Body Mass Index (BMI) (weight in kg/height in m2)

0=less than 19

1=BMI 19 to less than 21

2=BMI 21 to less than 23

3=BMI 23 or greater ……….

 

If BMI is not available, replace the previous question with the following:

Calf circumference (CC) in cm

0=CC less than 31

3=CC 31 or greater ………

 

FINAL SCREENING SCORE:

(Maximum 14 points)

 

12-14 points:  Normal nutritional status..…….

8-11 points:  At the risk of malnutrition.……….

0-7 points:  Malnourished……….

 

To complete the MNA form, first, fill in the information at the top of the form. Note that pounds should be converted to kilograms (kg) by dividing by 2.2. Measure height without shoes.  If measuring height directly is not possible, height may be estimated by using knee height, demi-span or half-arm span. Inches must be converted to centimeters (1 inch=2.54 cm).

Complete the form by filling in on the dotted lines with the appropriate numbers.  Total the numbers to obtain the FINAL SCREENING SCORE.

 

Ask the patient or caretaker or find in the medical record answers to the following questions:

“Have you eaten less than normal during the past three months?”

“Do you have a lack of appetite or chewing or swallowing difficulties?

B “Have you lost weight without trying during the past 3 months?”

If so, how much?  More or less than 3 kg (or 6 lbs)?

 

C  “Are you able to get out of bed, chair or wheelchair without help? “Do you go out of the house?”

 

D  “Have you been stressed or severely ill in the past 3 months?

 

E  “Do you have psychological problems?

See medical chart or ask care-taker or see medical chart for diagnoses and degree of severity.

 

Calculate BMI weight in kilograms/ height in meters X height in meters

 

If BMI is not available, replace with measurement of calf circumference in centimeters.   Wrap the tape measure around the calf at the widest place, and note the measurement. (note:  tape should be at a right angle to the length of the calf.

 

Then add the numbers to get the Final Screening Score.

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A PRACTICAL APPROACH TO INTERVENTION IN MALNUTRITION OF THE ELDERLY

 

Lack of calories and protein are the main nutritional problems in the elderly.  Consultation with a professional dietitian/nutritionist is recommended for patients with complex needs.  A general rule for the elderly is that prevention, whenever possible, is better than cure.

Common feeding problems in the elderly may include:  chewing and swallowing difficulty, respiration, appetite loss, diarrhea and malabsorption, and polypharmacy.  With polypharmacy, the physician should try to remove or replace those medications which have anorexic-producing side effects.

The elderly often have an inability or unwillingness to consume adequate amounts of foods in order to maintain stable, acceptable nutritional status.

Elderly with an MNA score of 8-11 points are “At Risk of Malnutrition”, when coupled with weight loss, nutrition intervention is indicated.  Diet enhancement, oral nutrition supplementation and weight monitoring with in-depth nutrition assessment by a professional dietitian/nutritionist are all options.

 

Persons with an MNA score of 0-7 points are considered “Malnourished”.  Treatment includes nutritional intervention such as diet enhancement, partial or total nutritional supplementation, nasogastric or gastrostomy(PEG) tube feeds, or parenteral nutrition support are all options.  Close weight monitoring and blood test monitoring of hemoglobin, albumin, total protein, creatinine, urea and additional blood tests according to the physician’s instructions, are important. Needless to say, an in-depth nutritional assessment by a professional dietitian/nutritionist is essential.

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MNA-SF SCORE

12-14 points          Normal Nutritional Status      No weight loss     No treatment necessary

8-11 points            At Risk of Malnutrition          Weight loss                  Treat

0-7 points           Malnutrition                         Serious Weight Loss      Treat

 

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NUTRITION SUPPORT

 

DIET ENHANCEMENT

The first step in nutrition support is to increase the nutritional intake of regular foods and drink (26).  One can increase the frequency of eating, providing small meals and snacks throughout the day. The goal is to maximize the nutrient and energy density of foods and drink, fortifying them with an addition of fats and sugars.  High-quality protein foods are also provided. Cake and other high-calorie snacks in between meals for the elderly should be considered a part of their regular food intake, and not as an extra occasional treat.

Make certain that the food texture suits their chewing and swallowing ability.  Provide ground or blended foods when chewing or swallowing are compromised. Additions to increase calories in regular foods may include milk, oil, butter, margarine, cheese or protein powders (egg, whey, soy) to increase protein intake.

 

NUTRITIONAL SUPPLEMENTS

Consider using home-made products or commercially manufactured oral nutrition supplements when elderly persons cannot take in enough nutrients by eating regular foods, are lactose-intolerant, will not eat high-calorie snacks or cannot safely prepare food (27).  Ensure sufficient fluid intake. When a specific nutrient deficiency is found, use of a micronutrient supplement may be indicated. Physical activity should be encouraged.

It is important to emphasize that use of supplements should be in addition to regular foods.  They should not be used as meal replacements unless the person refuses regular foods, or his intake of regular foods is inadequate.  In extreme cases, all regular foods may be temporarily stopped, and supplements should be provided to give concentrated amounts of essential nutrients until the person’s appetite improves.  Then a gradual transition back to regular foods may be possible. As regular food intake improves the amount of supplement can be reduced.

Nutritional supplements may come as a powder added to water or milk, or as ready-to-use liquids.  Use of oral supplements may be limited by a lack of compliance, often due to low palatability, adverse side-effects such as nausea or diarrhea, or by cost (5).  Best results are often seen when a variety of flavors and consistencies are provided, and when the temperature at which the products are consumed is varied.

 

ENTERAL NUTRITION

Use of manufactured products for patients requiring tube feeding is considered for persons who cannot eat and drink safely or adequately (28).  This may occur, for example, in persons with dysphagia following a stroke. It may also be considered when people cannot maintain an adequate food intake from regular foods and drink or from oral supplements.  If tube feeding is for long-term, insertion of a gastrostomy/PEG (Percutaneous Endoscopic Gastrostomy) in place of nasogastric tube feeding is considered. This option will contribute to patient comfort. As well, it is less likely to be displaced, and it can be concealed under clothes.

PARENTERAL NUTRITION

This is a method of providing nutrition directly into the venous system; either via a peripheral vein or through a central venous line.  In this way, one avoids using the digestive system. Parenteral nutrition is mainly employed during hospitalization, but at times, it is used in the community, mainly with persons with severe Crohn’s disease, vascular damage to the intestine or some persons with cancer.

In conclusion, nutritional assessment and treatment should be an important and routine part in the primary care of all elderly persons. Prevention of malnutrition is always preferred. Through the various techniques discussed here, improvement of the nutritional status of the elderly is possible, when the high-risk persons are identified through nutritional assessment.

 

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(2)Amarya, S., Singh, K., Sabharwal, M. Changes during aging and their association with malnutrition, Journal of Clinical Gerontology and Geriatrics, 2015; 6, 78-84.

 

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(4)Mitchell, C.O., Lipschitz, D.A. Detection of protein-calorie malnutrition in the elderly, American Journal of Clinical Nutrition, 1982, Feb. 35 (2), 398-406.

 

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Is it possible to increase weight and maintain the protein status of debilitated elderly residents of nursing homes?  Journal of Gerontology, Medical Sciences, 2005, vol. 60A, no. 7,878-881.

 

(6)Paillaud, E., Herbaud, S., Caillet, P., Lejonc, J.L., Campillo, B., Bories, P.N., Relations between undernutrition and nosocomial infections in elderly patients, Age Ageing, 2005, 34 (6), 619-625

(The International Journal of the British Geriatrics Society)

 

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(10)Boulos, C., Salameti, P., Barberger-Gateau, P., Social isolation and risk for malnutrition among older people, Geriatric Gerontology International, 2017;  17: 286-294

 

(11)Eskelinen, K., Hartikainen, S., Nykanen, I. Is loneliness associated with malnutrition in older people?  Int J of Gerontology vol. 10, issue 1, March 2016, 43-45

 

(12)Wellman, N., Weddle, D.O., Kranz, S., Brain, C.T.  Elder insecurities: poverty, hunger, and malnutrition, Journal of the American Dietetic Association, vol. 97, issue 10, supplement Oct 1997, S120-122

 

(13)Amarya, S., Singh, K., Sabharwal, M. Changes during aging and their association with malnutrition, Journal of Clinical Gerontology and Geriatrics, 2015, 6; 78-84

 

(14)Ortolani, E., Landi, F., Martone, A.M., Onder, G., Bernabei, R.

Nutritional status and drug therapy in older adults, J Gerontol Geriat Res, 2013,2;  123

 

(15)Jyrkka, J. Polypharmacy and nutritional status in elderly people,  Current opinion in clinical nutrition and metabolic care,2012, vol. 15; 1-6

 

(16)Shimazaki, Y.,Soh, I., Saito, T., Yamashita, Y., Koga,T.  Influence of dentition status on physical disability, mental impairment, and mortality in institutionalized elderly people, Journal of Dental Research,2001, vol. 80, issue 1,

 

(17)Baker, H.  Nutrition in the elderly:  diet pitfalls and nutrition advice, Geriatrics, Oct. 2007, vol. 62, issue 10, 24-26

 

(18)Wendland, B. E.,Greenwood, C.E.,Weinberg, I.,Young, KWH Malnutrition in institutionalized seniors: the iatrogenic component, Journal of the American Geriatrics Society, 2003, vol. 51, issue 1, 85-90

 

(19)Jonkers-Schuitema, C., Klos, M., Kouwenoord, K., Kriuizenga, H., Remijnse-Meester, W.Guideline screening and treatment of malnutrition, June 2011, The Dutch malnutrition steering group, info@fightmalnutrition.eu, www.fightmalnutrition.eu

 

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(21)Bouillanne, O., Morineau, G., Dupont, C., Coulombel, I. Vincent, J.P., Nicolis, I., Benazeth, S., Cynober, L., Aussel, C. Geriatric nutritional risk index:  a new index for evaluating at-risk elderly medical patients 1’2’3’, American Journal of Clinical Nutrition, Oct 2005, vol. 82, no. 4, 777-783

 

(22)Ellia, M. editor, Screening for malnutrition.  A multidisciplinary responsibility. Development and use of the Malnutrition Universal Screening Tool (MUST) for adults, British Association of Parenteral and Enteral Nutrition 2003

 

(23)Beck, A, Ovesen, L.,Osler, M. The Mini Nutritional Assessment (MNA) and the Determine your Nutritional Health Checklist (NSI Checklist) as predictors of morbidity and mortality in an elderly Danish population, British Journal of Nutrition, 1990, 8131-36

 

(24)Knodrup, J., Allison, S.P., Ellia, M., Vellas, B., Plautg, M. ESPEN guidelines for nutrition screening, 2002, Clinical Nutrition 2003, 22;  415-421

 

(25)Kaiser, M.J., Bauer, J.M., Ramsch, C. et. al. Validation of the mini nutritional assessment short form (MNA-SF).  A practical tool for identification of nutritional status, J Nutr Health Aging, 2009, 13; 782-788

 

(26) Flanagan, D., Fisher, T., Murray, M., Visvanathan,R., Charlton, K., Thesing, C., Quigley, G., Walther, K.  Managing undernutrition in the elderly, prevention is better than cure, Australian Family Physician, Sept. 2012, vol. 41, no.9; 695-699

 

(27)Johnsen, C., East, J.M., Glassman, P. Management of malnutrition in the elderly and the appropriate use of commercially manufactured oral nutrition supplements, J of Nutri Health and Aging, 2000, vol. 4, no. 1; 42-46

 

(28) Dwolatzky, T., Levinson, Y.  Practice and ethics of enteral feeding in the elderly, Aging Health, 2006, 2 (1), 1-12