Nutritionand

management in aged

RVS Chaitanya koppala

•Health is defined as the ability to function and live outside an institution.

•Aging is a gradual process that reflects the influence of genetics, lifestyle, and environment over the course of the lifespan.

•Adults generally need fewer calories with each passing decades.

Stages of adults:

• Early years – 20s to 30s

• Middle years- 40s to 50s

• Older years- 60s to 70s

• Oldest years- 80s and 90s

• State of health at any age is influenced by what is eaten.

• One cannot have the best of health unless one eats wisely.

• Maintenance and repair is the theme for nutrition and the adult.

• Child grows taller as he matures, adult lose stature.

• The cumulative effects of maturation, disease, medication and previous health practices influence the nutrient needs of adults.

• The mechanism of aging is a decline in the number cells along with the changes within the cells that damage the cellular organelles and changes in the basic genetic material that affect cell replication.

• The control of chronic conditions with medication and diet is a concern for many adults.

• The total nutrients needed for replacement and repair of the mature adult are more than the total nutrient needs of children except for calcium, phosphorus and vitamin D.

• The reduction in basal metabolism observed as a change accompanying aging and a reduction in activity explain the reduction in the suggested caloric intake.

Average women with sedentary lifestyle

AGE CALORIES23-50 1600-240051-75 1400-220075 and above 1200-2000

Average men with sedentary lifestyle

AGE CALORIES23-50 2300-310051-75 2000-280075 and above 1650-2450

Adult

• 1600 calories a day is about right for many sedentary women and some older adults.

• 2200 calories a day is about right for moderately

• active women, and most men.• • 2800 calories a day is about right for active

men• and some very active women.

Effects of agingEFFECT ON NUTRITION CAUSED BY ORGAN INVOLVED

ability to taste salt and sweets

taste buds Tongue and nose

Palatibility of food taste and olfactory nerve endings

Food intake

Taste and smell

Reduced sense of thirst/dry mouth

saliva production Salivary glands

Difficulty chewing Muscle contractions may malfunction

esophagus

Bioavailability of vitamins, minerals, proteins

HCl secretion and intrinsic factor

Stomach

Adrug doses (adjustments possible to avoid overdosing)

production of drug-matabolizing enzymes

Liver

EARLY YEARS (20s TO 30s)

• Their lifestyles are more time-restricted and positive health behaviors such as regular meal pattern and exercise may fall by the wayside.

• These years marks a transition from one stage of the life span to another; young adults separate from their family of origin; focus on personal goals, and often face reproduction decisions.

• Women bear children during these years

• For women , the recommended dietary allowance for energy is 2200 kcal daily.

• For men, 2900 kcal.

• This reflects the typical differences in body weight and lean body mass of men and women.

• Vitamin and mineral needs do not significantly change.

• Calcium and phosphorus needs for men and women decline after age 18 because skeletal growth is almost complete.

MIDDLE YEARS( 40S TO 80S)• Marked by a continuation of family demands and

career involvement.

• Kcaloric needs decline as lean body mass is lost and replaced by body fat that is less metabolically active.

• Body fat increases can be slowed by exercise and strength training to continue maintenance of lean body mass.

• After age 50, daily energy drop from 2200 to 1920 kcal for women.

• From 2900 to 2300 kcal for men.

• It is a challenge to meet the same nutrient needs with reduced kcaloric intake.

OLDER YEARS(60S, 70S AND 80S)

• As our life span increases in years, senescence (older adulthood) is for many a time of life for continued professional or career advancement and recreational enjoyment.

• Others are in transition, adjusting to retirement and settling into new patterns of activities.

• During these later years, individuals may struggle with deaths of family members and friends and adjustment to retirement.

• Disorientation or senility often associated with aging may be caused by improper use of medication, marginal nutrient deficiencies.

• Nocturia (inability to get to the toilet on their own)

• Fluid requirements in older adults remain the same as in younger adults ( about 8 cups a day) unless a medical condition.

• Nutrition status may be affected by restricted access to food and ability to prepare meals.

• Shopping may be difficult w/o transportation and mobility to walk through store may be limited.

• Adults may no longer have interest in cooking.

• Many continue to live in their own home with family members, some opt for retirement communities and others.

• Change in ability of the body to either process or synthesize certain nutrients.

• Adults need more exposure to sunlight.

OLDEST ADULT (80S AND 90S)• Aging continue to reduce the ability of the body

to absorb and synthesize nutrients.

• Malnutrition and underweight becomes concerns during this stage.

• Food preparation becomes physically difficult to accomplish.

• Kcaloric intake may diminish.

• Illness accompanying medications may reduce appetite

• Malnutrition is associated with complications

• Risk for dehydration

• Decrease ability of kidney to concentrate urine

• Limited movement

ADULT HEALTH PROMOTION

• Adequate intake of nutrients found in foods (rather than in supplements)

• Relationship between diet and disease

• Moderate kcaloric intake coupled with regular exercise for physical fitness and obesity prevention.

DETERMINE

Adults are risk for….

• Disease• Eating poorly• Tooth loss or oral pain• Economic hardship• Reduced social contact• Multiple medications• Involuntary weight loss or gain• Needs assistance with self-care• Elderly person older than 80 years

COMMON DISEASES IN ADULTS

HEART DISEASE

• Commonly considered a disease in men.

• The increase of cholesterol increases the risk of cardiovascular disease.

• A heart-healthy diet that is low in fat and saturated fat, ric in fruits, vegetables and whole grains.

CANCER

• 2ND leading cause of death.

• Lung cancer, breast cancer, colorectal cancer are 3 leading causes of cancer deaths.

• High intake of fruits and vegetables may protect against cancers.

• Rich in fruits, vegetables and whole grains is protective against breast cancer.

DIABETES

• Diabetes increase the risk of heart disease

• Obesity is implicated in the majority of cases of type 2 diabetes

• Weight management and a heart healthy diet are cornerstone of treatment.

OSTEOPOROSIS• Osteoporosis is a disease that is characterized by a

decrease in total bone mass and deterioration of bone tissue which leads to increased bone fragility and risk of fracture.

• Between 30 to 35 years of age, peak bone mass, the most bone mass a person will ever have is attained.

• During the first 5 years or so after onset of menopause, women experience rapid bone loss that is related to estrogen deficiency.

• The vertebrae, hip, and wrist are most susceptible to fracture.

• Decrease in stature and deformity reduce lung capacity and abdominal volume, which may lead to chronic back pain, and decrease tolerance in activity.

• Weight bearing exercise and calcium intake are important for building and strengthening bones.

PROSTATE CANCER

• Is associated with fat intake , particularly saturated fat.

• Men plder than 40 should be encouraged to undergo an unnual digital rectal examination or other forms of prostate cancer screening because overt symptoms may not occur until cancer ia advanced.

ADULT DISEASES AND CONDITIONS

• Aging Eye (including cataracts, glaucoma and macular degeneration)• Alzheimer’s and Other Dementias• Anemia• Blood Pressure (Hypertension)

• Kidney Disease• Lung Diseases (including COPD)• Memory Loss• Menopause• Osteoporosis

• Stroke• Thyroid Disorders• Urine and Bladder Problems

The key driver for eating is of course hunger but what we choose to eat is not determined solely by physiological or

nutritional needs.

• Biological determinants such as hunger, appetite, and taste

• Economic determinants such as cost, income, availability

• Physical determinants such as access, education, skills (e.g. cooking) and time

• Social determinants such as culture, family, peers and meal patterns• Psychological determinants such as

mood, stress and guilt• Attitudes, beliefs and knowledge

about food

Nutrition assessment in the

elderly people

• With age, metabolism decreases• Body composition changes• Muscle mass decreases as adipose tissue increases• Results in 2% deceased metabolic rate per decade• Decreased physical activity – less energy expenditure

Aging and Energy Needs

30% of elderly consume less kilocalories than recommended (Lengyel et al 2008) Decreased intake due to : Loss of appetite – depression, dementia Medication-induced anorexia Impaired taste perception Decreased density of taste buds (Winkler et al 1999) Higher thresholds for detection of tastes Loss of teeth Socioeconomic factors or functional disability effecting shopping and meal preparation .

Nutrient Consumption

Malnutrition is closely related to increased mortality and

morbidity• Greater susceptibility to infection and longer hospital stays Escott-Stump 2008), increased risk of medical and surgical complications (Baker and Wellman 2005), increased risk of

pressure ulcers, hip fractures (Escott-Stump2008)

• Incidence of malnutrition estimates range from 20 – 78 % (Bouillanne et al 2005)

Incidence of Malnutrition

Those with low lean body mass – about 25%of elderly population over the age of 65

Loss of muscle strength, physical inactivity, slow or unsteady gait, poor appetite, unintentional loss of weight, impaired cognition and depression (Escott- Stump 2008)

Proper nutrition can help correct, butphysical activity is also necessary

Frail Elderly or FTT

Compared to 20yr olds, 80yr olds need 1000 to 1500kcals less in men 600 to 800kcals less in women (Wakimoto et al, 2001)

Protein needs remain same with age or slightly higher (Elmadfa and Meyer 2008) 0.8 to 1gm/kg body weight Kilocalorie protein supplement (i.e.Boost, Ensure) may be helpful in preventing muscle wasting with inadequate total kcal intake (Evans 2004)

Fat intake among the elderly is greater than the recommended 35% or less of total kilocalories (Meydani 2004)

Macronutrient Needs

Vitamin and mineral needs remain unchanged withAge

Decreased food intake often results in deficient intakes of micronutrients

50% of older persons have lower than recommendedintakes of micronutrients (Escott-Stump, 2008) 80% of elderly persons have inadequate intakes of atleast on nutrient (Guigoz et al 2004)

Digestion, absorption, and synthesis ofmicronutrients are decreased (Elmadfa and Meyer, 2008)

Aging and Micronutrient Needs

Micronutrients of Concern

Vitamins 1 . Vitamin E 2 . Vitamin C3 . Vitamin D4. Vitamin A 5. Thiamine

Minerals 1 . Selenium 2 . Zinc 3 . Calcium 4 . Iron

High homocysteine levels resulting from B6, B12, folate deficiencies linked to increased cardiovascular disease risk and decreased mental agility

Folate deficiencies linked to increased dementia and depression (D’Anci et al 2004) Excessive folate intake can mask B12 deficiency

Corrects hematological signs of deficiency but not neurological signs Neurological signs include fatigue, malaise, vertigo, cognitive impairment (Clarke et al 2003)

Deficiency Risks

• Diuretics increases water-soluble vitaminslosses as urinary excretion is increased• Thiamine is especially at risk of becomingdeficient due to diuretics• Low dose thiamine supplement in the elderlyon diuretics may be useful in preventing

deficiency (Escott-Stump 2008)

Thiamine and other water soluble vitamins

Commonly deficient – Lengyel et al 2008found 10%, 84%, 49% of subjects deficient respectively

Frail elderly are more likely to be deficient vitamin E and A (Michelon et al 2006)

Centenarians are more likely to have high levels of Vitamin E and A (American Dietetic Association 2005)

Needed for drug metabolism and detoxification

Vitamins A, E, and C

Vitamin C, E, beta-carotene needed in adequate supply for

decreasing oxidative damage to tissues and cells including

immune cells

Balanced diet seems to be more effective

than supplementation for improved immune function but

supplementation maybe effective

Antioxidants

Bone mass decreases with age especially in women resulting in osteoporosis Direct health care cost of $12-18 billion each year just for fractures (USDHHS 2004) Absorption of calcium and vitamin D effected by age - receptor expression in duodenum decreases

Vitamin D synthesis decreases (MacLaughlin et al 1985) Less time spent exposed to sunlight (Escott-Stump 2008) Vitamins A and K, and magnesium effect bone health as well, but more research needed (American Dietetic Association

2005)

Calcium and Vitamin D

Depression in the elderly is associated with low levels of selenium (Gosney et al 2008)

Low levels of selenium, zinc, and iron linked to reduced cell-mediated immune response

(Wintergerst et al 2007)

Low zinc intake associated with increased wounds and severity (Tobon et al 2008)

Selenium, Zinc, Iron

Evaluating Malnutrition: Clinical/History

• Age• Weight (current &usual)• Dentition• Dysphagia• Skin condition• Constipation/Diarrhea• Current medications

• I/Os• Changes in appetite• N/V, indigestion• Pain• Infection• Motor coordination• Morbidities

Evaluating Malnutrition:Lab Work

• Glucose• C-reactive protein (CRP)• Ca++, Mg++• N-3, K+• H&H, serum Fe

• Serum folate• Serum homocysteine• Albumin,prealbumin, or transthyretin• Cholesterol

• Increased total number of medications associated with decreased appetite (Elmadfa and Meyer 2008)

• Evaluate for alcohol abuse Can cause severe deficiencies of thiamine, folate, vitamin

B12, and zinc May not admit to true amount being consumed• Screen for caffeine use May promote cognition Excessive use can have diuretic effect (Escott-Stump 2008)

Further Recommendations for Screening and Treatment

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