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Nutrition care in Aging

Nurpudji A TaslimNutrition Department School of Medicine

Hasanuddin University

@2009

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Topic of study Classification

Factors Contributed to Aging

Process

Nutrition Requirement

Program perbaikan gizi Lansia

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CLASSIFICATION

Older population- 55 years older population

- 65 years elderly population

Median Age (In 2000)

- developed countries = 37,4 years

- developing countries = 24,3 years

Life Expectancy (US, 2000)

- average for the population = 76,9 years

- = 79,5 years

- = 74,1 years

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Indonesiadeveloped country has high life expectancy

In Indonesia

2000 7,28%

2020 11,34% (BPS92)

2025 41,4%

Highest in the world

(US Bureau Statistic)

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Aging influences by:

gender

race/ethnic compositioneconomic status

presence of disease

health behavior

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RATE OF LIVING

A finite amount of vial substance that

when depleted result in aging and death

SOMATIC MUTATION

Spontaneous changes in the structure of

our genescannot be corrected oreliminatedaccumulate cause cells to

malfunction & die

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Physiologic changes

Growthanabolic

Agingcatabolic

Physiologic age- reflects health status- may or may

not reflect chronologic age

Lifestyle factor

- adequacy &regularity of sleep

- frequency of consumption well balanced meal- physical activity

- smoking status

- alcohol consumption

- body weight

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Body composition changes

-aging marked 2-3% loss of lean body mass (LBM)/decade- sarcopenia-loss of skeletal muscledecreased muscle

strenghtincreased risk for chronic disease

- resting metabolic rate decreased 15-20%

- reduce energy needs less LBM, >>Fat

Sensory losses

- smell, taste, sight, hearing, touch diminished

- number of papilla (tongue) & olfactory nerve

endingreduce appetite & pleasure of food,

food borne illness

- hearing loss, impaired vision, loss of functional

statuslower food intake

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Oral health status

- xerostomia (dry mouth) difficulty in chewing andswallowing

- dental caries & periodontitis tooth & bone loss

- eat less efficientlyfood intake

Gastrointestinal function Changes in nutrient intake, absorption & metabolism

(McIntosh,2001)

Mucosal immune response (Beharka, 2001)

Dysphagia Gastritis atrophyaffect bioavailability of nutrients,nutritional statusrisk developing chronic disease

AchlorhydriaB 12 deficiency (Ziesel, 2000)

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Constipation

Most common digestive complaints caused by

prolonged recto-sigmoid transit time

Limitation of mobility or activity Psychology factor

Medication

Manage

dietary fiber, fluid and kilocalories

physical activity

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Cardiovascular function

- blood vessel less elasticity

total peripheral resistancerisk for hypertension

- inadequate blood flow to the heartCV disease (USA)

- correction of hypertension and hyperlipidemiacost

effective in morbidity and mortality

Renal function

- malfunction & GFR 60%

- ability of the kidney to concentrate urine less able to

respond changes in fluid status (acid-base balance)

- >> of protein waste product & electrolytesdifficult tometabolizedneed dietary modification

- complication related to kidney functiondehydration,

hemorrhage, cardiac failure, improper use of

diuretics/toxic antibiotics

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Neurology function

- cerebral function-synthesis of neurotransmitter

- less efficient nerve conduction- less sleep

- changes in central nervous systemdiminished coordination

&balance, changes in mental equity & sensory interpretation,

les dexterity, mood alteration & difficulties with information

retrieval

- need time to identifydepression, dementia, alzheimers &

parkinsons disease

Immuno-competence

- affected humoral & cell mediated immunities especially T-cell

component

-prevalence of infections

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MEDICATIONS

-1/3 medication prescribed in USA are unnecessary

(Morrison and Hark, 1999)

- poly-pharmacyrisk of adverse drug reactions &

drug-nutrient interactions- Concernpathologic factor (CV, Liver, renal. GI

mal-absorption)

- complete drug history reduce risk & lead to safer

medication usage- appropriate nutrition assessment, intervention and

counseling should be implemented to prevent or

correct drug-nutrient interactions and improve

nutritional status (Nelms & Anderson, 2002)

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Age-Adjusted Prevalence of Overweightand Obese U.S. Adults Ages 20-74 Yr)

Overweight or Obese

(BMI 25) 47 56 61

Overweight(BMI 25-29,9) 32 33 34

Obese (BMI30) 15 23 27

NHANES

(1976-1980)(N= 11,207)

NHANES

(1988-1994)(N= 14,468)

NHANES

(1999)(N= 14,446)

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MULTIDISCIPLINARY

ASSESSMENT

Multidisciplinary approach Measures and mobility

Measures and functional status

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Activities of Daily Living and InstrumentalActivities of Daily LivingActivity of Daily Living

Eating

moving into and out of beds and chairs

being mobile and outdoors

dressing

toiletingmaintaining continence

Instrumental Activities of Daily Living

using the telephone

traveling

shopping

preparing meals

doing light housework

taking medication

managing money

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Nutrition Screening

Older adult risk for malnutrition Presence of disease - Physical disabilities

Poor dental and oral health - Poly-pharmacy

Poly-pharmacy - Social isolation

Financial limitation - Impaired mental health

Important for primary care

Advantage: Cost effective - improve the quality of life

Promote health - reduce complication

Reduce health care costs - delay admission into nursinghomes

Reduce complications and hospital length of stay

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Nutritional Health checklist warningsign use DETERMINE

Disease

Eating poorly

Tooth Loss/mouth pain Economic hardship

Reduced social contact

Multiple medicine

Involuntary weight loss/gain

Needs assistance in self-care

Elder years above age 80

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NUTRITIONREQUIREMENT

BASED ON

NUTRITIONAL STATUS

HEALTH STATUS

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NUTRITIONAL NEEDS

Energy

requirement (changes in body composition, BMR, physicalactivity)

Energy need BW, BEE, REE/TEE, actual BW

Average calories intake:

2000 kcal/day1600 kcal/day

Protein

Campbell,1996

- protein intake 1g /kg BB

- stress-full physical & psychological stimulinegative

nitrogen balance

-infectionaltered GI function &metabolic changes

reduce efficiency of dietary nitrogen and nitrogen

excretion

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Biomarker

Albuminindicator of protein status

Pre-albumin and RBPevaluate response to therapy

Carbohydrate

Needed to protect protein from being used as energy source

Approximately 45 -65% of total energy

Complex carbohydrate legumes, vegetables, whole grains &fruits to provide phyto-chemical &essential vitamins & mineral

Lipid

25-35% of total energy

Reduced SFA

Reduced fatweight control & cancer prevention

< 10% fataffect quality of diet and negatively affect taste,satiety & intake.

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Vitamin A

Fescanich et al,2002: high losses of vitamin A hip fracture

Sources of vitamin Adark green, leafy & yellow-orange

fruits and vegetablesprovide adequate food excessive -caroteneprecursor vitamin A

Vitamin C

Older adult have lower serum level of vitamin C

Vitamin C requirement increase : stress, smoking, medication

Encouraging the consumption of vitamin C-rich food most

effective

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Vitamin D

Depend on concentration of calcium andphosphorus in the diet

Age, sex, degree of exposure to sunlight (

decreased 60%) Functionheal skin lesionspsoriasis,

hyperproliferative disorder of cancer, actinickeratoses

Need moderate supplementation of vitamin Dand calciumimprove bone density and preventbone fracture (Dawson-Hughes 1977)

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VITAMIN E Epidemiologic studies

Vit E reduce the risk of CVD by reducing

the susceptibility of LDL tooxidationvascular endothelial cell

expression of proinflammary cytokine

(Meydani, 2001) Vit Ecancer prevention

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Vitamin B6 Many studiesolder adults do not consume

enough B6

Atrophic gastritis, alcoholism&liverdysfunctionrequirement

Severe deficiencyhomocysteine

levelanemia&risk for cardiac disease

Encouragedfolate rich foodliver, driedbeans, broccoli, avocado, asparagus&spinach

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Vitamin B12 Elderlyneed screening for B12

Prevalence 10-15% in age 60 (Baik& Russel,

1999), cause: athropic gastritis, bacteriaovergrowth, anemia pernicious, crohnsdisease, ileal resection, malabsorbtion

syndrome(Hoffbrand & Provan, 1997)

Supplement vit.B12 or injectable for all olderadults

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Water Daily fluid replacement is essential Exercise regularly

Consume large amount of protein

Use laxative or diuretics

Live in areas wit high temperatures

Need 30-35 ml/kg BB (actual body weight) orminimum 1500 cc/d

Increased agetotal body water decreases(50%) associated with a correspondingdecrease LBM

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Older risk for dehydration

Reduced thirst sensation

Reduced fluid intake Limited access to fluid

Disminished renal function

Urinary inconvenience

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Symptoms of dehydration

Electrolyte disturbance Altered drug affected

Headache

Constipation

Thirst, Loss of skin elasticity

Weight loss

Cognitive status deterioration

Dizziness

Dry mouth & nose mucous membranous

A swollen or dry tongue Change blood pressure

Rosessed or sunken eyes

Change in urine color or output

Speech difficulties

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An insufficient fluid intake with

frequent diarrhea or vomiting, fever,

illness, organ failure or chronicdiseaserequiring hospitalization

Careful monitoring of fluid intake &output is important

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Dietary Planning Food with nutrient density

Sufficient fluid, Ca, Fiber, Iron, Protein, Folic acid & vitamins (A,D, B12 & C)

Food is the best source of vitamins

Kauffman et al, 2002-- Supplements is often unnecessary;Vitamins, minerals, herbal supplementsused for non specificreason to stay healthyaware potentially toxic doses

Basic diet planning principles for older based on RDA

4 or 5 smaller meals

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Nutrition Issues Older risk of malnutrition

Lack of education

financial constraints Decreasing physical & psychological abilities

Social isolation

Treatments for multiple Concomitant disorder/diseases

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Nutrition Assessment Tinggi lutut

Laki-laki (2,02x55cm)-(1,04x umur/th)+ 64,19

Perempuan

82(1,83x55cm)-(0,04x umur/th)+ 84,88

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Secondary causes ofmalnutrition Feeding impairment

Anorexia

Mal-absorption (GIT dysfunction)

Increased nutrient needsinjury or

disease

Drug nutrient interactions

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Disease Issues OlderPopulation Dysphagia

Pressure ulcers

Alzheimers

Parkinsons

Geriatric failure

DM type II

Hypertension & constipation

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Dysphagia Food can chopped, ground or pureed ---

eating regular consistencies

The consistency of liquids can bemodified to thin, nectar, honey or puddingconsistencythickening agent

Appropriate body positioningreducedthe risk of chocking

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Pressure ulcers Most common

Location below the waist , but can develop anywhere

Especially: DM, CV (peripheral), chronic illness,cognitive impairment, mobility problems,incontinence, neurologic impairments.

Inadequate food; kilocalories, protein, zinc andvitamin C.

Frequent monitoring of BW, skin integrity, lab.value for nutritional status

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Management of PressureUlcers Based on stage and depth of damage

Therapy; frequent repositioning, use of supportsurfaces, moisture reduction, debridement andnutritional support

Risk factors: BW 15%, serum albumin level

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lzh im rs Alzheimers degenerative brain disorder

irreversible memory loss and intellectual andpersonality deterioration--- malnutrition

2,5 millionsUSA Fluctuate food intakeemotional state,

confusion level

Strategic to improve care can involve providinga simple, predictable environment and frequentcues relating to daily activities

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Parkinson diseases Neurodegenerative disease that affects

voluntary movement

Characterized by loss of brain cells thatproduce dopamine(a chemical that help direct

muscle activity)

Intervention includes; medication, exercise,

nutrition management, particularly in thecoordination of dietary protein adequacy and

timing ofintake with medication

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FAILURE TO THRIVE Malnutritioncompromises the immune

system--contribute to development:

Infection/sepsis Delayed wound healing

MODF

disability

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Key Factors For Assessing

Those At Risk For MalnutritionWeight loss

BMI < 21

Serum albumin

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Conclusion

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masalah gizi usia lanjut

GIZI LEBIH:Ditandai kegemukan/obesitas

penyakit degeneratif

Diabetes Melitus

Jantung Koroner MCI Gagal Ginjal

Hipertensi stroke

Asam urat, kolesterol, lemak

sirosis hati, asam empedu kanker

Penyakit sendidan tulang (beban >>)

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masalah gizi usia lanjut

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STATUS GIZI PADA USILAKondisi Usia Lanjut Perubahan Pola Makan Status Gizi

1. Metabolis basalmenurun Kebutuhan kalori menurun Cenderungkegemukan/

obesitas

2. Aktivitas/kegiatan fisik

berkurang

Kalori uang dipakai sedikit Cenderung

kegemukan/

obesitas

3. Ekonomi meningkat Konsumsi berlebih Cenderung

kegemukan/

obesitas

4. Fungsi mengecap/

penciuman

menurun/hilang

Makan tidak enak/nafsu

makanmenurun

Kurang gizi (Kurang

Energi Protein

Kronis/KEK)

5. Penyakit periodental

atau gigi tanggal

Kesulitan makan yang

berserat (sayur, daging),

cenderung makan

makanan yang lunak (tinggi

kalori)

Dapat terjadi KEK

atau kegemukan/

obesitas

STATUS GIZI PADA USILA

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6. Penurunan sekresi asam

lambung dan enzimpencerna makanan

Menggganggu

penyerapan vitamin danmineral

Defisiensi zat-zat

gizi mikro

7. Probilitas usus menurun Susah buang air Wasir (perdarahan

anemia)

8. Sering menggunakan

obat-obatan/alkohol

Menurunkan nafsu

makan

Kurang gizi

Hepatitis/kankerhati

9. Gangguan kemampuan

motorik

Kesulitan untuk

menyiapkan makanan

sendiri

Kurang gizi

10. Kurang bersosialisasi,kesepian (perubahan

psikologis)

Nafsu makan menurun

Kurang gizi

11. Pendapatan menurun

(pensiun)

Konsumsi makan

menurun

Kurang gizi

12. Demensia (pikun) Sering makan atau lupa

makan

Kegemukan/obesita

s atau kurang gizi

Kondisi Usia Lanjut Perubahan Pola Makan Status Gizi

STATUS GIZI PADA USILA

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PROGRAM PERBAIKANGIZI USIA LANJUT

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MASALAH GIZI USILA

INTERNAL

EKSTERNAL

BIOLOGI (PROSES MENUA )

INDIVIDU

LINGKUNGAN

F kt M hi

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Faktor yang MempengaruhiStatus Gizi Usia Lanjut

KONSUMSI

PENYAKIT

INFEKSI/

DEGENERATIF

KELUARGA/

PENGASUH

LINGKUP

PERGAULAN/

KELOMPOK

MASY.

Pendidikan

Proses menua

biologi

Faktor

Faktor

individu

Ekonomi

Hig.san/l ingk.

Sos-bud

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DASAR HUKUM1. UUD 1945, pasal 27 ayat 2 dan pasal 342. UU No. 4 th. 1965, ttg Pemberian Bantuan

Penghidupan Orang Tua

3. UU No. 6 th. 1974, ttg Ketentuan-KetentuanPokok Kesejahteraan Sosial

4. Program PBB ttg Lanjut Usia, anjuranKongres International WINA tahun 1983

5. UU no 23 th. 1992 ttg Kesehatan6. UU No. 10 th. 1992, ttg Perkembangan

Kepend. dan Pemb. Keluarga Sejahtera

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7. UU No. 11 th. 1992 ttg Dana Pensiun

8. Hari Lanjut Usia Nasional yang

dicanangkan oleh Presiden RI tanggal 29

Mei 2002 di Semarang9. UU Kesejahteraan No. 13 th. 1998, ttg

Kesejahteraan Lanjut Usia

10.Tahun Lanjut Usia Internasional th. 1999

11.UU No. 22 th. 1999, ttg Pemerintah Daerah

12.PP No. 23 th. 2000, ttg Otonomi Pemerintah

Daerah dan Desentralisasi

DASAR HUKUM

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KEBIJAKAN PROGRAM1) Meningkatkan kesehatan &

kesejahteraan masyarakat (USILA)

2) Penanggulangan penyakit kronis

dan degeneratif

3) Memperpanjang usia harapan hidup

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STRATEGI PROGRAM1) Paradigma Sehat Menuju

Indonesia Sehat 2010

2) Peningkatan kualitas pelayanan

oleh tenaga kesehatan bermutu

(Profesionalisme)

3) Sistem pembiayaan bersama

(Mandiri) mengarah pada asuransi

kesehatan masyarakat4) Desentralisasi pelayanan

kesehatan: mendekatkan

pelayanan dan tanggung jawab

OG

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TUJUAN PROGRAMGOALS :

Meningkatkan status kesehatan usila agar tetapproduktif melalui pelayanan gizi yang bermutu

TUJUAN KHUSUS:

1) Meningkatkan kualitas penyuluhan dankonseling gizi

2) Meningkatkan kualitas pelayanan gizi

3) Meningkatkan kualitas tenaga gizi utkmenangani pelayanan gizi pd usila

4) Meningkatkan status gizi

5) Meningkatkan kualitas SDM (Usila)

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LIFE CYCLE

SASARAN PROGRAM

Usila : > 60 tahun

Pra-usila : 50-60 thn

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IMPLEMENTASI PROGRAM

Menuju Pelayanan gizi paripurna

(Tim Asuhan Gizi ~ Tim Geriatri)

Penyuluhan (Health Promotion)

Perlindungan Khusus (Spesifik Protection)

Deteksi Dini (Early Detection)

Pengobatan segera (Prompt Treatment)

Mencegah ketidak mampuan (Disability Limitation)

Rehabilitasi (Rehabilitation)

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PELAYANAN

DI RUMAH SAKIT/PUSKESMAS DTP

Penyuluhan Gizi

Pelayanan Gizi Rawat InapPelayanan Gizi Rawat Jalan (Klinik Gizi)

Penyelenggaraan Makanan

Kunjungan rumah

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PELAYANAN

DI PANTI SOSIAL TRESNAWERDHA

Penyuluhan Gizi

Penyelenggaraan makanan

Konseling Gizi

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PELAYANAN DI POKSILA

Penyuluhan GiziKonseling Gizi

PELAYANAN DI KELUARGA

Nasihat Gizi

Penyiapan makananKonseling Gizi

Alur Pelayanan Gizi Usila

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Alur Pelayanan Gizi UsilaRUMAH SAKIT

Rawat

Inap

Rawat

Jalan

TimGeriatri

SMF Lain

PUSKESMASDengan/Tanpa Perawatan

PSTW Keluarga Poksila

SMF = Staf Medik Fungsional

P b P

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Pengembangan ProgramKekuatan : Partisipasi dan aktivitas Poksila

Keluarga besar Pola patrilinial

Kesempatan implementasi pelayanangeriatri (standar)

Dukungan Pemda (desentralisasi)

Kepedulian LSM & ormas daerah

Kelemahan : Biaya hidup/poverty (miskin, pensiun

kecil) Kurangnya sarana & prasarana

Keterbatasan tenaga & tempat pelayananyang berkualitas

Kurang kepedulian (kel & masy)

Bukan prioritas pemerintah daerah

Kesempatan : Perkembangan ilmu geriatri

Pendayagagunaan sarana & jaringanpelayanan serta rujukan yang sudah ada

Dukungan pemerintah (UU & PP)

Kepedulian LSM & ormas

Standar/jaringan pelayanan geriatri danrujukan

Sistim pembiayaan kesehatan (asuransi)

Ancaman : Peningkatan jumlah Usila beban

pemerintah menyediakan fasilitas

Tidak produktif dan ketergantungan

Perubahan gaya hidup (keluarga inti)

Perubahan pola penyakit (biaya tinggi)

Krisis ekonomi dan ke tidak stabilan

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Untuk meningkatkan kesehatan B : erat badan berlebih agar dihindari A : turlah makanan dg gizi seimbang

H : indari faktor risiko peny. degeneratif

A : gar terus berguna dgn memp. hobi yg

bermanfaat

G : erak badan teratur terus dilakukan

I : man dan taqwa ditingkatkan, hindarisituasi yg menegangkan

A : wasi kesehatan dgn pemeriksaan bdn scrberkala

(Prof. Dr. Slamet Sayono, RSCM, 1997)

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