Undernutrition in the old agecosts and treatment implications

Undernutrition in the old agecosts and treatment implications Danit R Shahar, RD, Ph. D

Danit R Shahar, RD, Ph. D The S. Daniel Abraham International Center for health and Nutrition Ben-Gurion University-Israel v Clinical dietitian v Ph. D in nutrition epidemiology v Ph. D Thesis: Factors associated with dietary intake and eating habits of community dwelling elderly people living in Pittsburgh, USA Areas of interest: v Dietary assessment methods v Factors associated with undernutrition among the elderly

Personal Statement v My professional commitment is to study and develop research programs and teach students of all health disciplines the topic of geriatric nutrition. v The work may create these people as leaders in their communities and thus change people views and attitudes toward older people.

Learning objectives: v To understand the concept of undernutrition among the elderly population v To understand the implications of undernutrition in terms of health consequences, cost and treatment v To be familiar with the main risk factors and causes for nutritional deterioration and deficiencies v To understand the basic concepts of dietary assessment of the elderly population

Nutritional status of the elderly populationthe prevalence of undernutrition l COMMUNITY SURVEYS: v 35 -40% < 2/3 RDA calories (Bidlack 1992) v 70 --78%< RNI* calories (Payette, 1995) v 48 -60% < RNI* Protein (Payette, 1995) l NURSING HOME SURVEYS: v 5 -18% < RDA calories (Rudman, 1989) v 0 -33% < RDA protein (Rudman, 1989) *RDA=Recommended Dietary Allowances **RNI=Recommended Nutrient Intake-Canadian recommendations-Different approach than the RDA

Nutrient NHANES III (1971 -74) (1976 -80) (1988 -91) Calories 16%-18% Riboflavin 6%-36% Vitamin B 6 50%-90% Vitamin A 42%-65% Vitamin C 23%-58% Calcium 40%-50% 20%-30% 7%-13% 54%-69% 22%-36% 22%-31% 30%-43% 25%-40% 15%-20% 25%-50% 25%-30% 15%-25% 25%-50% Table I: Percentage of inadequate intake of nutrients based on NHANES I II and III data (The NHANES III data is based on NCHS/CDC)

Dietary intake as compared with the DRI: (Negev Nutrition Study):

Do we treat undernutrition? v Mc. Whirter & Pennington BMJ, 1994 -Only 2% of undernourished hospitalized patients are being treated. 5% were referred to treatment during their hospitalization. . v During hospitalization 64% of the patients have lost weight. v 70% showed improvement in their nutritional status after treatment.

General consequesnces of undernutrition: v Weight loss is associated with a decline in function ability (Allison, 1992) v Delayed wound healing (Hill, 1992) v Impairment of the immune system which may increase the risk and consequences of infection (Chandra, 1988) v With severe weight loss, both cardiovascular and gastrointestinal functions are impaired v Malnourished people may become depressed and apathetic (Brozek, 1990)

General consequesnces of undernutrition II: v Loss of muscle strength (Lesourd BM, 1995) v Increase in fractures v Increased incidence of pressure sores v Specific micronutrient deficiencies

Malnutrition and post-surgical complications (Meguid, 88) P<0. 001

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 (n=67) Normally nourished pt. With $7, 375 major complications (n=20) Malnourished pt. With no $3, 469 complications (n=312) Normally nourished pt. With no $2, 968 complications (n=304)

Energy balance: v Naturally there is a decrease in energy needs. v Till 70 years old there is a positive energy balance associated with weight gain v After age 70 we can see a negative balance associated with weight loss. Lean body mass and body fat tend to be reduced (Morley) v Weight loss in the older age is associated with increased mortality and morbidity

Weight, weight change, and mortality in a random sample of older community-dwelling women -JAGS 47: 1409 -1414 k. White older community-dwellers women are at increased risk of mortality if they are underweight, lose weight or weight cycle

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

Risk facrots for undernutrition v Physiological – – – factors: Impaired senses of smell/taste Dental problems Decreased gastric acid secretion Medication/Medical problems Decreased mobility affecting purchase and preparation of foods

Drug therapy in the old age Nutritional aspects v Multiple medication due to co-morbidities v Effect of medications on digestion and absorption v Direct effect of medications on appetite v Medication may decrease or distort taste and smell v Certain medication may cause oral dryness v Certain medication may decrease mobility of the stomach and gastrointestinal tract v Diarrhea and decreased absorption (antibiotics) v Behavioral aspects v Changes of nutritional needs (diuretics)

Medication and appetite: Increase appetite and food intake v Steroids v Sex hormones v Antipsychotic v Antihistamin v Prokinetic v Kanavis Decrease appetite and food intake v Sympathomimetics v Anti-parkinsonian [L-dopa, Sinemet] v Antidepressants, SSRI, Prozac and realted Rx v Xantines [Theophylline] v Digitalis

RISK FACTORS FOR MALNUTRITION: (cont) v Socioeconomic – – v factors: Declining income and retirement Smaller household size Loss of spouse Isolation and institutionalization Psychological factors: - Depression Stressful life events mental confusion

Eating habits and caloric intake – NNS results: Decreased appetite, low snacking, gastrointestinal problems and poor health status were associated with low caloric intake Click for larger picture ** ** ** *

Other risk factors for undernutrition among the elderly population: v Eating less than needed-fewer products and smaller meals or portions v Decreased appetite and early satiety v Changes in energy regulation v Changes in the levels and function of neuropeptides (NO decrease, CCK increase>>>early satiation) v Decreased enjoyment of eating

What patients are at risk for nutritional deterioration? v Cancer v Cardiovascular Heart Failure v Chronic Obstructive Pulmonary Disease (COPD) v Post-surgery v Gastrointestinal diseases v Liver Cirrhosis v Renal Failure v Depression v Dementia These diseases may be hypermetabolic and / or induce anorexia

What are the most typical nutritional deficiencies in the old? v Vitamin B 12 (Usually not dietary) v Folic acid v Vitamin B 6 v Antioxidants vitamins v Zinc v Vitamin D v Calcium v Vitamin K

Factors associated with nutritional deficiencies v Eating lower nutritional quality foods such as bread and butter exclusively v General and specific deficiencies due to higher needs, co-morbidity and multiple medications. v Physiological and pathophysiological changes in the gastrointestinal system impact the ingestion and digestion of nutrients v Unnecessarily restrictive diets

Risk factors: Socioeconomic Psychological Physiological Loss of motivation/will to eat General deterioration “I am not important to anyone” Nutritional deficiencies Eat small amounts

Intervention strategies: Treatment of risk factors Better eating Regaining physical and emotional strength Quality of life improve

Weight as a key measurement for nutritional status v Weight history is one of the simplest and most consistent measure (Mobarahan 1991) v Weight change is a key variable in nutrition assessment in the elderly (Jeejeebhoy 1991) v Recent weight loss is a sensitive indication of individuals at nutritional risk (Fogt 1995)

Weight loss as an indication of nutritional deterioration v An involuntary weight loss of 10% of more especially over a short period of time v weight loss of 1 kg per week, 2 per month. v Weight loss trend over time

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

Recommendations: v Dietary assessment as part of geriatric assessment v Healthy eating v Encourage Snacking v High quality drinks or supplements (shakes) v Caution with prescribed “medical” diets v Judicious use of medication v Treating risk factors (depression) v Fortified foods v Supplements [energy!!! + nutrients] v Encourage weight stability, avoid loss!!!