Nutrition Aspects in Elderly

1
Nutrition Aspects in Elderly

• Pranithi Hongsprabhas
• Division of Clinical Nutrition, Department of
  Medicine, Faculty of Medicine, KKU

2
Outline

• Nutritional disorders
• Over nutrition
• Under nutrition
• Etiology of malnutrition
• Nutrition related problems

3
Introduction

• Changes in aging ? nutritional risk
• ? Organ system reserve
• Weaken homeostasis control
• ? heterogenicity of response
• Genetic
• Environment

4
Geriatric failure to thrive (FTT)

• FTT state of decline
• Decline in vitality
• The causes of deterioration not identifiable or
  irreversible..

Undergo a process of functional decline,
progressive apathy and loss of willingness to
eat and drink that culminate in death
5
4 Syndromes of FTT

• Impaired physical function
• Malnutrition
• Depression
• Cognitive impairment

6
Manifestation

• Weight loss gt 5 of baseline
• Appetite
• Poor nutrition
• Inactivity
• Accompanied by
• Dehydration
• Depressive symptoms
• Impaired immune function
• Low cholesterol

7
Undernutrition syndrome in elderly

• More common
• home 2-32
• Long term care 25-60
• Institution 1-83
• Hospital 30-65
• Greater impact less able to adapt to
  underfeeding
• Less frequent hunger
• Not regain total of weight

8
Consequences

• Functional disabilities
• Nosocomial infection
• Perioperative complication
• Morbidity, mortality
• Longer LOS
• Increased health care expenditure

9
Etiology of under nutrition

• Inadequate intake (starvation)
• Altered absorption
• Nutrient loss
• Nutrient metabolism

10
Weight loss in elderly

• Inadequate intake
• Inflammatroy effect of illness (cachexia)
• Muscle atrophy (sarcopenia of elderly)

11
Nutrient intake in elderly

• Anorexia
• Physical illness organ dysfuction, cancer,
  infection
• Mental illness
• Medication
• Poor oral/dental health
• Dysphagia
• Visual impairment

12
Influence of dental status on dietary intake
13
GI problems in elderly and their relations to
Nutritional disorders

• Dysphagia
• Oropharygeal
• Esophageal
• Atrophic gastritis
• Delayed GET
• Dyspepsia
• Diverticulum
• Colonic cancer

14
Atrophic gastritis

• Type A pernicious anemia (autoimmune)
• Type B
• Chronic inflammation
• Associated with HP
• ? Secretion of
• Acid
• Pepsin
• Intrinsic factor

15
Nutritional consequence of atrophic gastritis

• ?availability and absorption of B12
• (food-cobalamin malabsorption)
• ? Ca absorption
• ? non heme Fe absorption

16
B12 deficiency

• Megaloblastic anemia
• Neurological damage
• SCDS
• Dementia
• Atherosclerosis (hyperhomocysteinemia)

17
Nutrition metabolism related to body composition
changes

• Body composition
• ? Fat free mass
• ? Fat mass
• Energy expenditure
• Decreased with aging and ? lean body mass
• Increased
• Parkinsonism
• Cancer
• Infection
• Chronic cardiac failure
• Chronic pulmonary diseases

18
Nutrition metabolism related to body composition
changes

• Protein requirement increased
• ? catabolism in diseases
• ? synthesis

19
Cachexia

• Cancer
• Cardiac
• Pulmonary
• Chronic infection
• ? ?energy requirment 10-15
• ? ? protein requirement
• Hormonal control cortisol, catecholamine
• Cytokines TNF, IL-1, IL-6

20
Sarcopenia poverty of flesh

• ? lean body mass
• Concomitant ? fat mass

21
Multifactorial disorders

• ? sex hormone testosterone/DHEA
• ? GH and IGF-1
• ? cytokine production
• Neuromuscular changes
• Physical inactivity
• Malnutrition

22
(No Transcript)
23
Consequence of Sarcopenia

• ? energy expenditure
• ? insulin sensitivity
• ? muscle strength
• ? risk of disability
• ? risk of fall
• ? risk of mortality

24
Distinguishing sarcopenia from cachexia
Sarcopenia Cachexia
Appetite Not affected Suppress in early
Food intake Not affected ?
BW May ? ?
FFM ? ? ? ?
Alb N ?
Cholesterol May ? ?
Cortisol May ? ?
Inflammatory disease Not present Present
Response to refeeding Resistant Resistant
Pathway Not lead to cachexia May lead to sarcopenia
Clin Nutr 200626389-99
25
Exercise Training and Nutritional Supplementation
for Physical Frailty in Very Elderly People
Fiatarone MA et al. NEJM 1994 3301769-1775
26
Nutritional screening

• Mininutritional assessment (MNA)
• Screening
• Food intake (3mo)
• Wt change (3mo)
• Mobility
• Psychological or acute disease
• Neuropsychological preoblems
• BMI

27
MNA Assessment

• Lives independently (not in a nursing home or
  hospital)
• Takes more than 3 prescription drugs per day
• Pressure sores or skin ulcers
• How many full meals does the patient eat daily?
• Selected consumption markers for protein intake
• Consumes two or more servings of fruits or
  vegetables per day?
• How much fluid (water, juice, coffee, tea, milk)
  is consumed per day?
• Mode of feeding
• Self view of nutritional status
• In comparison with other people of the same
  age,how does the patient consider his/her health
  status?
• Mid-arm circumference (MAC) in cm
• Calf circumference (CC) in cm
• Malnutrition Indicator Score
• 17 to 23.5 points at risk of malnutrition
• Less than 17 points malnourished

28
Markers

• Screening tools
• MNA
• Hx
• Wt loss
• Dietary Hx
• Medical Hx
• Anthropometry
• Lab
• CBC
• Alb
• Chol

29
Nutritional Rx

• Rx causes of poor intake
• ? Nutritinal intake
• Diet
• Oral nutritional supplement (ONS)
• Enteral tube feeding (ETF)

30
Possible strategies to improve oral intake
Risk Interventional strategies
Loss of appetite Check drug Personally chosen food, Fortified menu appetizer
Chewing problems Dental care, oral hygiene, mushy food
Swallowing problems Speech Rx, ETF
Difficulties preparing food PT, nursing assistance
Chronic pain Analgesia
Depression Check medication, medical Rx
Social isolation Social service, meals on wheels
31
Enteral nutrition

• Oral nutritional supplement

32
ETF
Bourdel-Marchasson I, et al Nutrition. 2000
Jan16(1)1-5
33
Obesity in elderly
34
Diseases associated with obesity

• Cardiovascular, stroke
• HTN
• DM/Metabolic syndrome
• Dyslipidemia
• Cancer
• Breast
• Endometrial
• Colorectal

• GERD
• Cholelithiasis
• NASH
• OSA/OHS
• Asthma
• OA
• Gout
• Infertility
• PCOS
• incontinence

35
Degree of obesity and mortality in elderly
36
Relation between ? in Wt and RR of Type 2 DM,
HTN, CHD, and Cholelithiasis.
NEJM 1999341427-34.
37
Voluntary Wt Reduction in Older Men ? Hip Bone
Loss The Osteoporotic Fractures in Men Study
38
Association of Mild to Moderate Weight Loss with
All-Cause Mortality
Andres, R. et. al. Ann Intern Med 1993119737-743
39
Pattern of Weight Change Associated with Lowest
All-Cause Mortality
Andres, R. et. al. Ann Intern Med 1993119737-743
40
Treatment strategies

• Preventing weight gain and overweight healthy
  weights and
• avoiding further weight gain among those already
  overweight
• are important public health goals.
• Weight reduction in pts with mobility problem
• Therapeutic lifestyle control