Nutritional supports for improved health outcomes in older adults

Kathryn Star, PhD, RD

Objectives

• Understand the impact of malnutrition on the older patient

• Recognize factors in older adults that contribute to nutritional risk

• Identify nutritional risk and malnutrition in older patients

• Describe nutrition optimization and its associated benefits

Malnutrition is a Critical Issue

van Stijn M, et al., JPEN, 2013; White JV, et al., J Acad Nutr Diet, 2012

Consequences of Undernutrition

• Precedes disease and hospitalization• Loss of lean mass and bone• Slow wound healing• Longer hospitalization stays• Higher readmission rates• Increased mortality

NUTRITIONAL RISK

UNDER‐NOURISHEDUNDER‐WEIGHT

UNDER‐ NOURISHEDOBESE 

NUTRITIONALLY VULNERABLE

Physiological/Biomedical

Psycho/Social 

Economical

Psycho/Social EnvironmentalEconomical

Aging

Aging Related Protein Intake Shortfalls

Bauer J, et al. J Am Med Dir Assoc. 2013;14:542‐549

Prevalence of Malnutrition Across the Continuum of Care

Community-dwelling Older Adults

• Psycho/ Social– Mental health– Cognition– Loneliness– Social Isolation– Lack of social support– Alcoholism– Bereavement– Eating alone

• Environmental/Economic– Financial constraints – Access to food– Food preparation– Living alone– Transportation– Neighborhood walkability– Safety

Porter Starr KN, McDonald SR, Bales CW. Current Nutrition Reports. 2015:1‐9.

Hospitalized Older Adults

• Comorbidity• Admitting illness/ surgery• Medications• Restrictive diets• NPO orders• Meal interruptions• Food preference• Psycho/ Social

Porter Starr KN, McDonald SR, Bales CW. Current Nutrition Reports. 2015:1‐9.

Older Adults in Post-acute Care/ LTC

• Communication during any transition– Medications– Dietary preferences/ needs

• Depression• Swallowing issues• Eating/ chewing difficulties• Immobility/ functional deficits• Insufficient staffing

Porter Starr KN, McDonald SR, Bales CW. Current Nutrition Reports. 2015:1‐9.

Challenges of Identifying Malnutrition

• American College of Surgeons – Routine nutritional status screen– Preoperative nutrition intervention

• American Medical Association– “comprehensive nutritional screening,

assessment and management”• No universal, validated screening tool• Occurs day of hospital admission

– What about those not admitted to hospital

How would you know if someone was at nutritional risk or

malnourished?

BMIWeight

Status

Below 18.5 Underweight

18.5 – 24.9 Normal

25.0 – 29.9 Overweight

30.0 and Above Obese

23.0

23.0

Identifying Malnutrition

• Albumin and pre-albumin are markers of inflammation NOT NUTRITIONAL STATUS

• AND/ASPEN Nutritional Focused Physical Exam – Gold-standard

• Validated Nutrition Screening– Nutritional Risk Screener-2002

• Validated Nutrition Assessment– Patient Generated- Subjective Global Assessment

ASPEN criteria (2 of the following)

• Weight loss – occurs at any BMI• Insufficient energy intake – <50-75% of

estimated needs • Loss of muscle mass – physical exam• Loss of subcutaneous fat – physical exam• Fluid accumulation – localized or generalized• Diminished function – Hand grip strength

Tappenden KA, et al. J Acad Nutr Diet. 2013;113(9):1219‐1237

Mild to Moderate MalnutritionAcute Illness/Injury Chronic Illness 

Weight Loss1‐2%/1 week5%/1 month

7.5%/3 months

5%/1 month7.5%/3 months10%/6 months20%/1 year

Energy Intake <75% for >7 days <75% for ≥1 month

Body Fat Mild Depletion Mild Depletion

Muscle Mass Mild Depletion Mild Depletion

Fluid Accumulation Mild Mild

Hand Grip Strength N/A N/A

Severe Malnutrition in AdultsAcute Illness/Injury Chronic Illness 

Weight Loss>2%/1 week>5%/1 month

>7.5%/3 months

>5%/1 month>7.5%/3 months>10%/6 months>20%/1 year

Energy Intake ≤50% for ≥5 days ≤75% for ≥1 month

Body Fat Moderate Depletion Severe Depletion

Muscle Mass Moderate Depletion Severe Depletion

Fluid Accumulation Moderate/Severe Severe

Hand Grip Strength Not Recommended in ICU

Reduced for Age/Gender

NUTRITION INTERVENTION

What do we do about it?

• Refer to a Registered Dietitian Nutritionist• Always assess using standard tools and

act upon the findings• Avoid therapeutic diets• Improve the social aspects of eating• Dental care• Physical activity

Community• Supplemental Nutrition Assistance Program

(SNAP)• Geriatrics Workforce Enhancement Program• USDA Senior Farmers’ Market Nutrition

Program• Older American’s Act Nutrition Program

– Home delivered meals– Congregate meal programs– Nutrition education

Hospital

• Smaller meals with snack in between• Animal protein• Energy dense foods (i.e. healthy fats)• Nourishing fluids (i.e. milkshakes, soups)• Avoid therapeutic diets• Minimize NPO status• Use enteral nutrition with high protein

Surgical Patient• Nutritional support should begin 7-10 days

prior to surgery with established malnutrition– Oral supplementation preferred

• Following surgery, enteral, or parenteral nutrition should begin if eating has not begun by day 5

• Elective surgery should be delayed if patient is severely malnourished and nutrition intervention should be implemented immediately

Hospital: Oral Nutrition Supplements

• Use with a comprehensive treatment plan• Modest consistent weight gain• Consistency in intake across care settings • Provide a cup and/ or ice • Does not reduce meal intake/ total energy

intake when given 30-60 min before meals• Mortality benefit in undernourished

McDonald, SR. Beverage Impacts on Health and Nutrition: Oral Nutritional Supplementation Using Beverages for Older Adults. Humana Press, 2016.

• Reducing Diet Restrictions– American Dietetic Association Position Paper

supports removing restrictions as a way of enhancing food intake

– Emphasizes “person-centered” and “resident-centered” care

Niedert, K.C. J Am Diet Assoc. 2005;105:1955.

Post-acute care/ LTC

Nutrition Has To Be A Priority

• All providers must be empowered to influence nutrition decisions

• Recognize and diagnose all patients at risk• Intervention needs to be comprehensive and

promptly implemented before and after surgery.

• Nutrition care plan need to be documented and shared across care settings

• Refer to a Registered Dietitian Nutritionist