Undernutrition in the old age-costs and treatment implications

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Undernutrition in the old age-costs and treatment
implications

• Danit R Shahar, RD, PhD

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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

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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.

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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

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Nutritional status of the elderly population-the
prevalence of undernutrition

• COMMUNITY SURVEYS
• 35-40 lt 2/3 RDA calories (Bidlack 1992)
• 70--78lt RNI calories (Payette, 1995)
• 48-60 lt RNI Protein (Payette, 1995)
• NURSING HOME SURVEYS
• 5-18 lt RDA calories (Rudman, 1989)
• 0-33 lt RDA protein (Rudman, 1989)

RDARecommended Dietary Allowances RNIRecommen
ded Nutrient Intake-Canadian recommendations-Diffe
rent approach than the RDA
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Nutrient NHANES I NHANES II NHANES III
(1971-74) (1976-80)
(1988-91) Calories 16-18 20-30 25-40 Ribofl
avin 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 IPercentage of inadequate intake
of nutrients based on NHANES I II and III
data (The NHANES III data is based on NCHS/CDC)
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Dietary intake as compared with the DRI (Negev
Nutrition Study)
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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.

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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)

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General consequesnces of undernutrition II

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

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Malnutrition and post-surgical complications
(Meguid, 88)
Plt0.001
Plt0.001
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Cost of a stay in hospital in malnourished and
well nourished patients with or without major
complications (Reilly, 88)
Cost of average hospital stay
12,683 Malnourished pt. with major complications (n67)
7,375 Normally nourished pt. With major complications (n20)
3,469 Malnourished pt. With no complications (n312)
2,968 Normally nourished pt. With no complications (n304)
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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

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

• White older community-dwellers women are at
  increased risk of mortality
• if they are underweight, lose weight or weight
  cycle

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RR for mortality according to BMI among older
people 70 years and older AJCN 2001 55(6)482-492
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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

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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)

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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

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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

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Eating habits and caloric intake NNS
resultsDecreased appetite, low snacking,
gastrointestinal problems and poor health status
were associated with low caloric intake
Click for larger picture




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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 increasegtgtgtearly
  satiation)
• Decreased enjoyment of eating

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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
• Dementia
• These diseases may be hypermetabolic and / or
  induce anorexia

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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

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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

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Risk factors
Physiological
Psychological
Socioeconomic
Loss of motivation/will to eat
General deterioration I am not important to
anyone
Nutritional deficiencies
Eat small amounts
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Intervention strategies
Treatment of risk factors
Better eating
Regaining physical and emotional strength
Quality of life improve
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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)

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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

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Nutritional assessment

• Assessment of appetite
• Are all food groups included in each meal (5
  colors of food per meal)
• Enjoyment of eating
• Use of Mini Nutritional Assessment (MNA) or
  eating behavior questionnaires
• Biochemical and clinical assessment

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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!!!