Combating Malnutrition in the Elderly

Transcription

1 Combating Malnutrition in the Elderly Elaine Farley-Zoucha RD, LMNT EZ Nutrition Consulting, PC Malnutrition in the geriatric individual can lead to significant negative outcomes, therefore accurate and timely identification of malnutrition is essential to resident success. Foregoing a cookie cutter approach and individualizing nutrition intervention is key to the success of the resident. 1

2 Objectives 1. Explain signs and symptoms of malnutrition. 2. Identify out of the box approaches to combat malnutrition. 3. Identify key areas to monitor when replenishing the malnourished resident

3 Definition of Malnutrition An acute, subacute or chronic state of nutrition, in which a combination of varying degrees of overnutrition or undernutrition with or without inflammatory activity have led to a change in body composition and diminished function. This can involve inadequate intake of protein and/or energy over prolonged periods of time resulting in loss of fat stores and/or muscle wasting. The 3 etiology-based nutrition diagnoses are: "Starvation-related malnutrition": chronic starvation without inflammation (e.g., anorexia nervosa). "Chronic disease-related malnutrition": inflammation is chronic and of mild to moderate degree (e.g., organ failure, pancreatic cancer, rheumatoid arthritis or sarcopenic obesity). "Acute disease or injury-related malnutrition": inflammation is acute and of severe degree (e.g., major infection, burns, trauma or closed head injury. Add JPEN 2012; 36: a footer 3

4 Etiology Based Malnutrition Definitions JPEN 2012; 36: What We Know. Over 60 year olds are the fastest growing segment of the population. The elderly are at risk for weight loss, malnutrition, dehydration, and skin breakdown. Research shows that 50 75% of residents leave over 25% of their food uneaten at most meals % of residents have a physician or dietitian order to receive dietary supplements. 4

5 How Common is Malnutrition in Older Adults Many people over the age of 65 are either under or overnourished. Among older people living in their own homes, about 1 in 10 are suffering from under nutrition. Many healthy older adults report that they skip at least one meal a day. For people over the age of 65 who become hospitalized, their risk of becoming undernourished may rise to as much as 60%. How Common is Malnutrition in Older Adults Up to 85% of people who live in long term care facilities experience malnutrition in some form. On the other hand, as much as one third of people over the age of 65 suffer from over nutrition. That is, they eat too much. The result is a high rate of overweight and obesity in this age group. 5

6 How Common is Malnutrition in Older Adults Incidence of eating disability in nursing homes is high. Data collected by the CMS indicates that 28% of nursing facility residents require assistance with eating, and 19.2% are totally dependent on eating assistance. A decline in functional ability can be a factor in accessing adequate nutrition. The problem is enhanced by staff shortages and the length of time required to feed a totally dependent resident. In addition, many residents require coaxing and encouragement to eat, increasing the staff time requirement. Who Is At Risk? 6

7 Adults considered at risk are: Involuntary loss of 10% or more of usual body weight within 6 months, or involuntary loss of greater than or 5% or more of usual body weight in 1 month. Involuntary loss or gain of 10 pounds within 6 months. Body mass index less than 18.5 kg/m2 or greater than 25 kg/m2. Chronic disease. Increased metabolic requirements. Altered diets or diet schedules. Inadequate nutrition intake, including not receiving food or nutrition products for greater than 7 days. Causes and Symptoms Researchers have identified a number of risk factors that may increase your chance of becoming malnourished as you get older. These include: Physical Social Psychological 7

8 Physical Risk Factors General loss of appetite. Bad teeth or problems with chewing. Problems with swallowing, causing choking or food going down the wrong way. A feeling of being full too early. Dexterity problems, such as severe arthritis that may make it difficult to hold utensils or feed oneself. Physical Risk Factors Sensory problems, such as changes in taste, smell, and vision. Overall reduction in ability to digest and absorb many foods (because older people produce less stomach acid and fewer digestive enzymes). Mobility or transportation difficulties that make food shopping too much of a challenge. 8

9 Physical Risk Factors Respiratory disorders - emphysema Gastrointestinal disorders - malabsorption Endocrine disorders diabetes, thyroid Neurological disorders - cerebrovascular accident, Parkinson's disease Physical Risk Factors Infections - urinary tract infection, chest infection Physical disability - arthritis, poor mobility Drug interactions - Digoxin, Metformin, antibiotics, etc Other disease states - cancer 9

10 Sensory Changes Sensory loss is common in the aging process. Visual impairment can diminish the appreciation of the color of foods and the ability to recognize them. The flavor of foods may be altered for older adults because of loss of both olfactory and taste perception. Daily food intake can be improved by making food more appealing. Sensory Changes Attractive packaging, food color, texture, temperature, and flavor make it more likely someone will enjoy their food. Foods can be made more appetizing even if someone has a loss of taste or smell. You can use spices, foods of different colors, and interesting textures. Add lemon juice and herbs. Also, it is usually okay to use a little salt, unless the healthcare provider has said you shouldn t. If someone is experiencing under-nutrition, the healthcare provider may adjust diet restrictions to allow more flexibility in what they eat. 10

11 Dental or Oral Problems Dental or oral problems can impact eating. A person may experience trouble with poorly fitted dentures, missing or loose teeth, or jaw problems. Try to prepare foods so that they can be chewed easily, but without boiling them to uninteresting mush. Many foods can be chopped, stewed, or grated so that they are still appealing but easier to eat with dental problems. Trying to eat a healthy, well-balanced diet becomes much more difficult when teeth are weak, painful, loose or missing, or when dentures do not fit properly. About half of older adults have lost many, if not all of their teeth. Dental or Oral Problems Nutrition can suffer if a person has missing teeth, especially the back teeth that are needed for grinding up food. If someone is unable to chew and grind their food well, they might avoid eating nutritious foods like fruits and vegetables. Instead, they are more likely to rely on soft, easy-to-swallow refined foods, such as white bread, potatoes, or puddings. Also, their diet will be much less varied. This increases the risk of being overweight or obese, and leads to higher salt intake and cholesterol levels. Lack of variation in someone s diet also means that it is harder to get important nutrients like vitamins and minerals. 11

12 Chewing Problems A poor dental situation and mouth pain often lead to reduced intakes of fruits, vegetables, meat and more fibrous cereal foods. This can lead to lower intakes of vitamin C, vitamin A, folates, iron and zinc, nutrients that are particularly important for maintaining the immune system. Encourage adequate dental and mouth care. Try soft foods that require little chewing. Lactose Intolerance Many people have more trouble digesting dairy products when they get older. This can cause unpleasant side effects, such as diarrhea or loose bowel movements. However, there are good options for people with lactose intolerance. Some yogurts and aged cheeses like cheddar are naturally lower in lactose. You can also purchase lactose-reduced products such as milk and ice cream. 12

13 Problems with swallowing (dysphagia) Older people may have trouble swallowing. This can be caused by a variety of things, including dry mouth from medications, dementia, muscle loss, or diseases of the nervous system. Someone you are caring for may have increasing difficulty swallowing food, or regularly feel like food is going down the wrong way. Often, simple approaches can help the situation. Typically, thickened liquids are used to prevent aspiration. Sometimes these are not palatable for many people. Swallowing Difficulties Coughing and choking are common problems if drinks are not thickened. Change in types of foods eaten. This may reduce the intake of total food consumed and the intake of some important nutrients. 13

14 Swallowing Difficulties Change in texture of food. Patients with eating or swallowing difficulties may need altered textured diets and fluids, and this is likely to lead to lower energy density in meals which have been diluted. Patients on texture modified diets may only meet 45% of their energy requirements and require more frequent energy dense meals and snacks to obtain sufficient energy. Swallowing Difficulties Refer to a speech and language therapist who can assess and monitor patients with eating difficulties. Modify the consistency of foods as appropriate. Dehydration. This commonly occurs as fluid intake becomes more difficult with dysphagia. 14

15 Fluids/Hydration F692 Dehydration is the state of not having enough fluids in your body. Dehydration can be common in many older people because they do not feel thirsty even when they need to take in fluids. Consider diuretic, laxatives, and acute or chronic infections when assessing fluid needs. Skin Problems and Pressure Ulcers Malnutrition in older adults can lead to poor skin health. For example, there is a layer of fat under the skin that normally acts as a cushion against pressures from outside. When this cushion of fat disappears, an older person has a much higher risk of developing pressure sores or pressure ulcers. This is especially the case for older adults who spend much of their time in a chair or bed. These areas of skin breakdown often resist healing. The poor skin health in malnutrition is partly a result of protein deficiency. This leads to a lack of materials in the body to repair unhealthy tissue. It can also be a response to lack of certain micronutrients such as vitamins B2 or vitamin C. 15

16 Arthritis Arthritis or other conditions can make it difficult to use utensils easily. Consider utensils that are specially designed for people with arthritis. It can also be helpful to serve finger foods that can be picked up and held easily. Additional risk factors if resident is hospitalized Unpleasant sights, sounds, and smells. Increased nutrient requirement, for example, because of infections, catabolic state, wound healing, etc. Limited provision for religious or cultural dietary needs. Nothing by mouth or miss meals while having tests. 16

17 Social risk factors Living alone (particularly for older men). Loneliness/Isolation. Living in a nursing home or rehabilitation center. Lack of knowledge about food, cooking and nutrition. Cultural or religious traditions, allergies, or food intolerances that may limit food options. Social Isolation Meals on wheels and other meal delivery services also play a vital role in not only alleviating loneliness but also in improving dietary intake and helping prevent malnutrition in older people living alone. Check medication use. Consider counseling. Isolated older adults often experience a loss of appetite, eat fewer meals during a typical day and with this have a lower intake of protein, fruits and vegetables. 17

18 Lifestyle and Socio-economics Financial issues (for example, having to choose between purchasing food and paying for other necessary expenses such as medicines, heating bills, or rent/mortgage). Lack of Transportation. Poverty. Inability to shop or prepare food. Psychological Risk Factors Recent surgery or hospital stay. Alcohol or substance abuse. Cognitive impairment (dementia of any kind, such as Alzheimer s Disease). Inability to exercise. Depression. 18

19 Psychological Risk Factors Chronic or acute pain. Medications that decrease appetite, prevent nutrients from being absorbed, or upset digestion (causing constipation or other intestinal problems). Medical conditions that require people to limit their intake of salt, fat, protein, or sugar, making foods bland and tasteless. Anxiety. Bereavement. Dementia Older adults with dementia are at extra risk for malnutrition because they are unlikely to be able to shop and cook for themselves. People with dementia need a lot of help actually finishing the food that is placed in front of them. This is because these patients may not be physically able to chew and swallow well. 19

20 Dementia The situation is often complicated by the fact that many people with dementia do not like to accept help with eating. They may be taking sedatives or other medications that interfere with appetite or taste. If they are in a nursing home or long-term care facility, they are more likely to suffer from malnutrition. Depression Depression among institutionalized older adults is common and can be caused by several factors, including loss of loved ones, loss of independence, loneliness, and failing health. These factors can contribute to a resident's lack of attention to their nutrition needs and food preferences, which results in a decrease in food intake and often malnutrition. 20

21 Depression Many older adults take a variety of medicines and some of these may bring on a depressive mood. Increasing physical activity or an exercise routine can improve appetite, improve social interactions (if exercising in a group), and lessen depressive moods. Try to make mealtimes an enjoyable social occasion, with satisfying foods in a pleasant setting. Depression Check with a pharmacist or the healthcare provider about medications. They may be able to stop or adjust prescriptions that might be contributing to lack of appetite or depressed mood. Discuss whether an antidepressant medication or counseling might be appropriate. Consume alcoholic beverages in moderation. 21

22 Approaches and Suggestions Timely assessment by the Dietitian. Make sure the older person is getting enough fluids and that their mouth is not too dry. Having them suck on candies or chew gum may be helpful. Check to see how much food the person leaves on the plate after a meal. Approaches and Suggestions Try to serve the person foods that they prefer. Make meals a pleasant social event by including friends or family when possible. Serve more frequent small meals instead of three large ones. Offer nutritious snacks, including nutrient-rich drinks or protein bars. 22

23 How do we define malnutrition? Consensus Statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: Characteristics Recommended for the Identification and Documentation of Adult Malnutrition (Undernutrition) Jane V. White, PhD, RD, FADA, Peggi Guenter, PhD, RN, Gordon Jensen, MD, PhD, FASPEN, Ainsley Malone, MS, RD, CNSC, Marsha Schofield, MS, RD Journal of the Academy of Nutrition and Dietetics Volume 112, Issue 5, Pages (May 2012) DOI: /j.jand Warning Signs Loss of sensation. Signs of dehydration Decreased urination. Constipation. Dry mucous membranes Bruising easily. Sudden, unintended weight loss. Loss of appetite and decreased food intake. Poor Concentration/Confusion. Difficulty Breathing. Trouble Staying Warm. 23

24 AND/ASPEN Consensus Malnutrition Characteristics Unintentional weight loss Evidence of inadequate intake Loss of muscle mass Loss of subcutaneous fat Fluid accumulation Reduced hand grip strength The presence of two or more characteristics necessary for the diagnosis of malnutrition JPEN 2012; 36: Symptoms and Warning Signs Two obvious signs of malnutrition are increases or decreases in appetite or weight. Some less obvious warning signs include: Dull, dry hair Dry eyes Receding gums 24

25 Loss of Appetite Loss of appetite is a major cause of undernutrition in longterm care. As appetite diminishes, intake of total energy, protein, vitamins and minerals is reduced, depleting the body of necessary nutrients. Older adults are at an increased risk for illness and infection. Loss of Appetite Infections may lead to a higher metabolic rate, increasing the person's total energy and protein needs. Diet restrictions that limit familiar foods and eliminate or modify seasonings in foods may contribute to poor appetite, decreased food intake and increased risk of illness, infection, and weight loss. 25

26 Vitamins and Mineral Deficiencies Vitamin D. Iron. Calcium. Vitamin B12. Potassium. Magnesium. Sodium. Vitamin D Low vitamin D levels are now common in the United States, particularly in northern states where the winters are long and sunshine is weaker. It is especially problematic for older people who do not go outside very much, and who are malnourished. Healthcare providers may wish to order a blood test to check vitamin D levels. Most guidelines recommend at least 800-1,000 IU (international units) of vitamin D every day for older adults. 26

27 Vitamin B12 Older people are at increased risk of B12 deficiency. This is because they are more likely to have these certain risk factors: Poor nutrition. Reduced ability to absorb nutrients even if nutrition is enough (this can be caused by not having enough stomach acid and digestive enzymes). History of surgery where part of the stomach or small intestine has been removed. Taking antacids or other heartburn medicines long-term. Long-term alcoholism. Vitamin B6 Vitamin B6 is needed to keep your nerves functioning properly. B6 deficiencies are common in older adults and may cause: Tingling or numbness in feet and hands. Fragile skin and mucous membranes. Blood problems like anemia. Possible higher risk of heart and circulation problems. 27

28 Folic Acid Folate is also known as folic acid. Appears to have a protective function against heart disease and cancer. It is found in many foods, especially artificially fortified foods, as well as dietary supplements. Folate keeps your cells healthy, and helps in the production of new red blood cells and in the prevention of cancer. Folic Acid Folate deficiency can cause the following symptoms: High homocysteine levels. Anemia Fatigue and weakness. Diarrhea. Poor appetite and weight loss. Irritability, forgetfulness, and other unusual behaviors. Headaches or a sore tongue. 28

29 How Do We Detect Malnutrition The onset of nutritional problems is often gradual and therefore hard to detect. However, features found in the history and examination may help identify those at risk. People can present with a variety of problems that may be vague or non-specific. Patients may report reduced appetite and energy and have altered taste sensation and changes to their normal bowel habit. Clinical features that may suggest under nourishment include low body weight, fragile skin, wasted muscles, recurrent infections and impaired wound healing. How Do We Detect Malnutrition Conduct a physical examination. Reviewing medications (prescription and over-the-counter remedies). Many medicines affect appetite, digestion (including constipation), and nutrient absorption. Many medications may interfere with taste and smell. Asking about their daily routine and ability to carry out regular functions. Asking questions about memory and mood. 29

30 How Do We Detect Malnutrition A malnourished state is defined as any of the following: BMI < 18.5 kg/m 2 Unintentional weight loss > 10% within the last three to six months. BMI < 20 kg/m 2 and unintentional weight loss > 5% within the last month. How Do We Detect Malnutrition In many cases clinical judgment is sufficient to diagnose under-nutrition. However, not everyone who is malnourished is thin. Objective classification of a patient s risk of malnutrition assists clinical decision making. A validated and reliable nutrition screening tool is the first step in identifying at risk patients. 30

31 Laboratory Testing Laboratory testing is not useful for diagnosing malnutrition. Some tests may be required to detect specific deficiencies such as iron, folate and vitamin B12. Albumin has been suggested in the past as a marker of nutritional status but it is now regarded as unhelpful due to the fact that it can be altered by clinical conditions such as dehydration and inflammation. Laboratory Testing Serum proteins albumin, prealbumin (PAB), transferrin, and retinol-binding protein (RBP) are used to measure malnutrition. C-reactive protein (CRP), total lymphocyte count (TLC), and serum total cholesterol are not serum proteins but sometimes are used as indicators of malnutrition. Despite the standard use of lab tests to help diagnose malnutrition, experts have no consensus about which, if any, biochemical markers identify malnutrition, especially in the frail, elderly population. 31

32 Laboratory Testing -Transferrin Transferrin is used to evaluate protein and iron status. Inflammation leads to a decrease in transferrin; iron deficiency causes it to increase. In patients with iron deficiency, transferrin s use is limited. Like other negative acute-phase reactants, many underlying factors affect serum transferrin levels, putting its sensitivity as an indicator of nutrition depletion and response to depletion in question. Laboratory Testing -CRP CRP (C-Reactive Protein) is a nonspecific marker of inflammation. An elevated CRP reflects any type of inflammation. Decreases in CRP may help predict when inflammation is waning and when intensive nutrition therapy would help. CRP may serve as a useful indirect marker of undernutrition. 32

33 Laboratory Testing -TLC TLC (total lymphocyte count) and other immune deficiency markers may help predict malnutrition. TLC decreases in the presence of stress, tumors, sepsis, and steroid usage, independent of malnutrition. No single marker for immunocompetence, including total lymphocyte count, is effective for measuring malnutrition. Laboratory Testing Rather than relying on lab results, healthcare professionals must use their assessment expertise and critical thinking skills to diagnose malnutrition and develop an effective nutrition intervention plan. Lab results can provide overall trends but are only one piece of the puzzle. Additional data from the medical record, evaluation of meal consumption, physical exam, and a visit with the patient all will provide information about nutritional status. Thorough follow-up includes evaluating changes in weight, BMI, appearance, and physical condition to determine if nutrition interventions are having their intended effect or if modifications are needed. 33

34 Malnutrition Screening and Assessment Tools Mini Nutrition Assessment (MNA) Quick and easy-to-use screening tool. Calf circumference can be substituted for BMI in residents who can t be weighed or measured. Determine Checklist This checklist helps identify whether an individual is at nutritional risk. Simplified Nutritional Appetite Questionnaire. Malnutrition Universal Screening Tool (MUST) Validated screening tool suitable for adults in acute and community settings. Malnutrition Screening and Assessment Tools Malnutrition Screening Tool (MST) is a validated tool to screen residents for risk of malnutrition. Nutrition screen parameters include weight loss and appetite. Subjective Global Assessment (SGA) proven nutritional assessment tool that has found to be highly predictive of nutritionrelated complications in acute, rehab, community, and residential aged care settings. Nutrition assessment parameters include a medical history (weight, intake, GI symptoms, functional capacity) and physical examination. 34

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36 Interventions 36

37 Nutritional Supplements In the form of nutritional drinks, nutritional bars and cookies, or powders that can be added to drinks or other foods. Nutrient-dense, may have high or low calorie options, and often have good concentrations of vitamins and minerals. Nutritional supplements should not replace regular meals. Use them as snacks between meals or before bedtime. Interventions In some situations a Food First approach can be sufficient to correct malnutrition outcomes. For patients who are at very high risk of malnutrition or for whom first-line dietary measures are not sufficient, oral nutritional supplements should be considered in combination with the Food First approach. 37

38 Physical Activity Researchers have found that physical activity has many benefits in older people, particularly if they are undernourished: It can increase your appetite. It can improve your brain function, which helps you nourish yourself in a more healthy way. It may strengthen muscles and bone. It may improve many other types of conditions, including type 2 diabetes, osteoporosis, arthritis, and psychological illnesses such as depression. Combating Overnutrition The best dietary strategy is to decide on a target weight that is appropriate for the resident and that the resident agrees to; Aim for gradual weight loss. Educate resident and document on: Eating fewer calorie-rich foods. Increasing your consumption of nutrient-rich, high-fiber foods, such as vegetables and grains. Reducing portion sizes. 38

39 Drugs People who are very undernourished are sometimes given drugs to increase appetite, such as Remeron, Marinol, or Megestrol. Sometimes drugs are given to increase muscle mass, such as growth hormone or an anabolic steroid (for example, Nandrolone or testosterone). Prevention and Treatment Older people can be encouraged to eat more, and food can be made more appealing. For example, strongly flavored or favorite foods, rather than low-salt or low-fat foods, can be served. Older people who need help with grocery shopping or feeding themselves should be given additional assistance. For example, they could be set up to have meals delivered to their home. Older people may be following a special diet (such as a low-salt diet) because they have a chronic disease (such as kidney or heart failure). However, such diets are sometimes unappealing and lack taste. If so, people may not eat enough food. In such cases, they or their family members should talk to the dietitian or doctor about how to improve foods that will taste good to them and that will fit within their dietary requirements. 39

40 Prevention and Treatment Depression and other disorders, if present, should be treated. Treating these disorders may remove some of the obstacles to eating. For older people living in institutions, making the dining room more attractive and giving them more time to eat may enable them to eat more. Prevention and Treatment Liberalize diets to improve food palatability, allowing residents varied food options and choices. Diabetic residents with poor intake may be placed on less restrictive or a general diet as long as blood sugar is monitored regularly. Review recipes to make sure foods are seasoned well. Many times salt is omitted in some recipes including general diets. Pureed foods are frequently not salted or seasoned properly. Check for food variety, seasonal food items and color combination. Garnish plated foods at serving to enhance aesthetic appearance. Provide on-going education to dietary staff regarding menu compliance, food portions and appropriate use of serving scoop sizes to guarantee nutritional adequacy of meals served, particularly pureed and other textured diets. 40

41 Prevention and Treatment Avoid serving oral supplements like fortified health shakes during meals. Residents tend to feel full once a supplement is consumed at the beginning of meal, therefore, will not attempt to eat the food served. Offer fortified foods to residents who are losing weight to increase their caloric intake. Additional butter or margarine, sour cream, or cheese may be added to certain foods, for example, potatoes, pastas, or vegetables. Substitute whole milk with meals instead of 2%. Offer oral supplements, snacks or nourishments in between meals. A recent study shows that supervised delivery of additional foods and fluids between meals (10 a.m., 2 p.m., and 7 p.m.) resulted to significant increase of food and fluid intake to 90% of residents with low intake. A snack and hydration cart that looks enticing can be wheeled around and made accessible to residents. Prevention and Treatment Provide proper assistance to residents during meals. Start a complimentary ice cream shop to be open to residents daily to encourage socialization. This can be run by volunteers. Develop a creative, fun shake program for high risk residents or residents with poor intakes. Activity staff can get a small group of residents together in the afternoon and blend healthy, nutritious shakes. 41

42 Prevention and Treatment Encourage resident participation in menu planning at least once a month to incorporate their favorite foods or choices. Keep the Resident Food Council active. Review and update meal delivery or system to promote a homelike dining or meal experience to residents that may arouse some familiarity of how meals used to be at their own home. Encourage physical activity or exercise, if possible, to promote appetite and increase oral intakes. Residents often complain of not having appetite because they are not doing anything. References 1. New Dining Practice Standard, Pioneer Network Food and Dining Clinical Standard Task Force (Aug 2011), 2. Nutrition Basic Facts and Information Nutrition for Older Adults, posted (Mar 2012), updated (Jan 2018), 3. Position of the American Dietetic Association, Liberalization of the Diet Prescription Improves Quality of Life for Older Adults in Long Term Care. Journal of Academy and Dietetics. 2015,105, Who is at Risk, Malnutrition: Healthcare Professional Tip Sheet, (2016), Alliance for Aging Research, 5. Must Tool Mini Nutrition Assessment, Nestles Nutrition Institute MNA elderly, 42

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44 Combating Malnutrition in the Elderly Elaine Farley-Zoucha RD, LMNT 44