الرحيم الرحمن الله بسم

THE ELDERLY: NUTRITIONAL NEEDS,

CHALLENGES CHALLENGES SCREENING AND SOLUTIONS

OBJECTIVES Describe how the nutritional needs of the elderlyare different from other adult populations •Identify several nutritional challenges facing

theelderly and the related healthcare risks •Describe the importance of nutritional

screeningand intervention with individuals at risk •List at least two nutrition intervention solutions

for the elderly

NUTRITION: A KEY COMPONENT OF SUCCESSFUL AGING AND QUALITY OF LIFE

Quality of Life Family, Caregivers, Community Social Interactions, Spirituality, Religion Independence, Living Arrangements Physical, Mental, Emotional Functioning Health Status, Disease Management Nutritional Well‐Being

AGE-RELATED CHANGES AND NUTRITION

Sacropenia, or the loss of lean muscle mass, can lead to a gain in body fat that may not be apparent by measuring body weight. It may be more noticeable by loss of strength,

functional decline, and poor endurance. This loss also leads to reduced total body water content.

Another common loss related to aging is changes in bone density, which can increase the risk for osteoporosis.

AGE-RELATED CHANGES AND NUTRITION

Many changes occur throughout the digestive system. A decrease in saliva production—xerostomia—and changes in dentition alter the ability to chew and may lead to changes in food choices.

There is a decrease in gastric acid secretion that can limit the absorption of iron and vitamin B12.

Peristalsis is slower and constipation may be an issue because fluid intake is decreased.

Appetite and thirst dysregulation also occur, leading to early satiety and a blunted thirst mechanism.

Sensory changes affect the appetite in several ways. Vision loss makes shopping, preparing food, and even eating more difficult.

Diminished taste and smell take away the appeal of many foods and may lead to preparing or consuming food that is no longer safe.

AGE-RELATED RENAL IMPAIRMENT

In addition to gastrointestinal physiological changes, renal function declines with age. This decreases responsiveness to antidiuretic hormone, which often results in an increased risk for dehydration in older patients. This impaired thirst drive makes it difficult to replete fluid losses by oral intake alone. Renal impairment may also affect vitamin D metabolism and result in a reduction of vitamin D levels, which contributes to osteoporosis in the elderly.

A comprehensive geriatric assessment also addresses psychosocial, environmental factors, and affective symptoms of weight loss in the elderly. The loss of a caregiver, the inability to drive a motor vehicle, or moving into a new apartment or residence may precipitate a decline in oral intake and cause weight loss. Depressive symptoms such as these are important considerations when evaluating the nutritional health of a senior patient (Hazzard et al 1994; Kane et al 1994; Williams 1995; Refai and Seidner 2001). It is especially important to ask older patients about alcohol intake, which may replace or suppress the consumption of foods with superior nutritional value. Alcohol misuse in the elderly is associated with impaired functional status, poor self-rated health, and depressive symptoms (St John et al 2002).

Even slight weight loss in the elderly is an independent predictor of morbidity and mortality. The medical causes of weight loss may be compounded by psychosocial and environmental factors.

PHYSIOLOGY OF AGING AND NUTRITIONAL STATUS

basal metabolism or energy requirements for the elderly diminish by about 100 kcal/day per decade. For some seniors it may be difficult to meet daily micronutrient requirements with this reduced caloric intake. To combat this, a multivitamin supplement for seniors is recommended , especially for those whose caloric intake is less than 1500 kcal/day .

PHYSIOLOGY OF AGING AND NUTRITIONAL STATUS Cardiovascular, pulmonary, and neurological

diseases, as well as osteoarthritis and osteoporosis, may alter energy requirements in the elderly either by increasing energy expenditure or reducing requirements through muscle loss related to inactivity. Actual energy needs may vary widely from calculated energy needs because of these factors. This makes the elderly a heterogeneous group and more difficult to assess nutritionally. An increase in metabolic requirements has not been associated with pressure ulcers (an unfortunately common condition in hospitalized elderly patients), although frequently concomitant conditions such as infection might encourage weight loss in older patients as a result of increased energy expenditure, decreased albumin, and protein undernutrition

NUTRITIONAL NEEDS OF HEALTHY ADULTS: ESTIMATED ENERGY REQUIREMENTS DECLINE WITH AGE

Male Female

30 years 2080 1762

80 years 1580 1412

NUTRITIONAL NEEDS OF HEALTHY ADULTS: MACRONUTRIENT DISTRIBUTION TO MEET ENERGY NEEDS

A balance of protein, carbohydrate and fat is needed,

even as calorie (energy) requirements decline with age %of total

calaverage% total calories

70 yrs1482

protein 10-35% 15% 224cals(56g)

Carbohydrate

45-65% 52% 772cals(193g)

fat 20-35% 33% 486cals(54g)

CURRENT PROTEIN RECOMMENDATION MAY NOT BE ADEQUATE FOR ELDERLY

Current RDA(Recommended Dietary Allowance)for Protein – Established for healthy men and women ≥19 yrs – 0.8g protein/kg/day – 46g/day (female) – 56g/day (male)

Increased Protein Suggested for Elderly To help maintain metabolic, physical

and functional status – 1.0 – 1.5g protein/kg/day – 58g – 86g/day (female) – 70g – 105g/day (male)

WATER INTAKE

Total Water*(liters/day) Male(19-70+): 3.7 Female(19-70+): 2.7*Total water includes all water contained

in food, beverages, and drinking water

TOTAL FIBER (GRAMS/DAY)

Total Fiber (grams/day) 19-50 51-70 71+ real intake male 38g 30g 30g 17.0g

female 25g 21g 21g 14.3g

Increasing dietary fiber may be useful in the treatment of constipation, glucose intolerance, lipid disorders, and obesity, as well as preventing diverticular disease and colon cancers. Reduction in sodium has been shown to reduce blood pressure and also reduce the risk of developing hypertension (Patterson 1994).

MICRONUTRIENT REQUIREMENTS FOR OLDER ADULTS (>50 YEARS)  Food and Nutrition Board Recommendations (RDA

except where otherwise noted) Recommendation Micronutrient Men Women  Vitamins    Biotin 30 mcg/day (AI)30 mcg/day (AI) Folic acid 400 mcg/day 400 mcg/day  Niacin 16 mgNE*/day 14 mg NE/day  Pantothenic acid 5 mg/day (AI)5 mg/day (AI) Riboflavin 1.3 mg/day1.1 mg/day Thiamin 1.2 mg/day1.1 mg/day Vitamin A 900 mcg (3,000 IU)/day700 mcg (2,333 IU)/day Vitamin B6 1.7 mg/day1.5 mg/day Vitamin B12 2.4 mcg/day#2.4 mcg/day#100-400 mcg/day of crystalline vitamin B12Vitamin C 90 mg/day75 mg/day≥ 400 mg/day Vitamin D (51-70 years) 15 mcg (600 IU)/day15 mcg (600 IU)/day2,000 IU/day from supplements Vitamin D (> 70 years) 20 mcg (800 IU)/day20 mcg (800 IU)/day2,000 IU/day from supplements Vitamin E 15 mg (22.5 IU)/day15 mg (22.5 IU)/day200 IU/day supplement of natural-source (RRR- or d-) alpha-tocopherol Vitamin K 120 mcg/day (AI)90 mcg/day (AI) Minerals 

Calcium (51-70 years) 1,000 mg/day1,200 mg/day Calcium (> 70 years) 1,200 mg/day1,200 mg/day Chromium 30 mcg/day (AI)20 mcg/day (AI) Copper 900 mcg/day900 mcg/day Fluoride 4 mg/day (AI)3 mg/day (AI) Iodine 150 mcg/day150 mcg/day Iron 8 mg/day8 mg/dayNo supplement Magnesium 420 mg/day320 mg/dayNo supplement providing > 350 mg/day Manganese 2.3 mg/day (AI)1.8 mg/day (AI) Molybdenum 45 mcg/day45 mcg/day Phosphorus 700 mg/day700 mg/day Potassium 4.7 g/day (AI)4.7 g/day (AI) Selenium 55 mcg/day55 mcg/day Sodium (51-70 years) 1.3 g/day (AI)1.3 g/day (AI) Sodium (> 70 years) 1.2 g/day (AI)1.2 g/day (AI) Zinc 11 mg/day8 mg/day *NE, niacin equivalent: 1 mg NE = 60 mg of tryptophan = 1 mg niacin

#Vitamin B12 intake should be from supplements or fortified foods due to the age-related increase in malabsorption

RDA=Recommended Dietary Allowance; AI=Adequate Intake

VITAMIN D generally healthy adults take 2,000 IU (50 mcg) of supplemental

vitamin D daily. Most multivitamins contain 400 IU of vitamin D, and single ingredient vitamin D supplements are available for additional supplementation. Sun exposure, diet, skin color, and obesity have variable, substantial impact on body vitamin D levels. To adjust for individual differences and ensure adequate body vitamin D status, aiming for a serum 25-hydroxyvitamin D level of at least 80 nmol/L (32 ng/mL). Numerous observational studies have found that serum 25-hydroxyvitamin D levels of 80 nmol/L (32 ng/mL) and above are associated with reduced risk of bone fractures, several cancers, multiple sclerosis, and type 1 (insulin-dependent) diabetes. Daily supplementation with 2,000 IU (50 mcg) of vitamin D is especially important for older adults because aging is associated with a reduced capacity to synthesize vitamin D in the skin upon sun exposure.

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CAUSES OF VITAMIN D DEFICIENCY IN THE ELDERLY

• habitually low dietary intake (120-200 I.U./d)• impaired synthesis in senile skin (see below)• little sun exposure in homebound and institutionalized elderly people

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RECOMMENDATIONS: (EXPERT PANEL OF THE NATIONAL OSTEOPOROSIS FOUNDATION, 2003)

Women under 50 should consume 1200 mg of calcium and 600 (800) IU of vitamin D

Physical activity

Active strategies to avoid falls

Avoid falls and the consumption of more than two alcoholic drinks per day

CALCIUM To minimize bone loss, older men (> 70 years) and

postmenopausal women should consume a total (diet plus supplements) of 1,200 mg/day of calcium. Men aged 51-70 years should consume 1,000 mg of calcium per day. No multivitamin/multimineral supplement contains the RDA for calcium (1,000-1,200 mg/day) because the resulting pill would be too large to swallow. If your total daily calcium intake doesn't add up to 1,000 mg, It is recommended to take an extra calcium supplement (combined with magnesium) with a meal.

MAGNESIUM Older adults are less likely than younger adults to consume

enough magnesium to meet their needs and should therefore take care to eat magnesium-rich foods in addition to taking a multivitamin-mineral supplement daily. However, no multivitamin/mineral supplement contains 100% of the DV for magnesium. If you don’t eat plenty of green leafy vegetables, whole grains, and nuts, you likely are not getting enough magnesium from your diet. If you add a magnesium supplement, It is recommended a combined magnesium-calcium supplement containing 133-250 mg of magnesium and 333-500 mg of calcium with a meal. Because older adults are more likely to have impaired kidney function, they should avoid taking more than 350 mg/day of supplemental magnesium without medical consultation

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Lack of vitamin B12

Causes-Poor intestinal absorption-Decreased binding with intrinsic factor eg:

-Gastric resection-Atrophic gastritis-Metabolic disorders

-Low consumption

Consequences- Pernicious anemia- Memory loss- Reduced motor coordination- Myopathia

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Sources of Vitamin B12

SODIUM There is consistent evidence that diets relatively low in salt (5.8

grams/day or less) and high in potassium (at least 4.7 grams/day) are associated with decreased risk of high blood pressure and the associated risks of cardiovascular and kidney diseases. Diets low in sodium and rich in potassium are likely to be of particular benefit for older individuals, who are at increased risk of high blood pressure. Moreover, the Dietary Approaches to Stop Hypertension (DASH) trial demonstrated that a diet emphasizing fruits, vegetables, whole grains, nuts, and low-fat dairy products substantially lowered blood pressure, an effect that was enhanced by reducing salt intake to 5.8 grams/day or less. It is recommended that a diet that is rich in fruits and vegetables (at least 5 servings/day) and limits processed foods that are high in salt. Sensitivity to the blood pressure-raising effects of salt increases with age; therefore, consuming diets that are low in salt and high in potassium may especially benefit older adults.

Diets rich in potassium (at least 4.7 grams/day) and low in salt (5.8 grams/day or less) are likely to be of particular benefit for older adults, who are at increased risk of high blood pressure along with its associated risks of cardiovascular and kidney diseases. Since sensitivity to the blood pressure-raising effects of salt increases with age, consuming diets that are low in salt and high in potassium may especially benefit older adults.

OTHER NUTRIENTS Essential Fatty Acids L-carnitine Flavonoids

ESSENTIAL FATTY ACIDS Alpha-linolenic acid (ALA), an omega-3 

fatty acid, and linoleic acid (LA), an omega-6 fatty acid, are considered essential fatty acids because they cannot be synthesized by humans. In 2002, the Food and Nutrition Board of the U.S.Institute of Medicine established adequate intake (AI) levels for omega-6 and omega-3 fatty acids. Essential fatty acid recommendations for adults over the age of 50 are listed below.

Adequate Intake (AI) for Essential Fatty Acids Essential Fatty Acid 

 ALA (> 50 years) Men  1.6 g/day  Women 1.1 g/day 

LA (> 50 years) Men  14 g/day  Women 11 g/day Abbreviations: ALA=alpha-linolenic acid; LA=linoleic acid; g=grams

American Heart Association RecommendationThe American Heart Association recommends that people without documented CHD eat a variety of fish (preferably oily) at least twice weekly, in addition to consuming oils and foods rich in ALA. People with documented CHD are advised to consume approximately 1 g/day of EPA + DHA preferably from oily fish, or to consider EPA + DHA supplements in consultation with a physician. Patients who need to lower serum triglycerides may take 2-4 g/day of EPA + DHA supplements under a physician's care.

L-CARNITINE Age-related declines in mitochondrial function and

increases in mitochondrialoxidant production are thought to be important contributors to the adverse effects of aging. Tissue L-carnitine levels have been found to decline with age in humans and animals . One study found that feeding aged rats acetyl-L-carnitine (ALCAR) reversed the age-related declines in tissue L-carnitine levels and also reversed a number of age-related changes in liver mitochondrial function; however, high doses of ALCAR increased liver mitochondrial oxidant production . More recently, two studies found that supplementing aged rats with either ALCAR or alpha-lipoic acid, a mitochondrial cofactor and antioxidant, improved mitochondrial energy metabolism, decreased oxidative stress, and improved memory . Interestingly, co-supplementation of ALCAR and alpha-lipoic acid resulted in even greater improvements than either compound administered alone

L-CARNITINE Age-related declines in mitochondrial function and

increases in mitochondrialoxidant production are thought to be important contributors to the adverse effects of aging. Tissue L-carnitine levels have been found to decline with age in humans and animals . One study found that feeding aged rats acetyl-L-carnitine (ALCAR) reversed the age-related declines in tissue L-carnitine levels and also reversed a number of age-related changes in liver mitochondrial function; however, high doses of ALCAR increased liver mitochondrial oxidant production . More recently, two studies found that supplementing aged rats with either ALCAR or alpha-lipoic acid, a mitochondrial cofactor and antioxidant, improved mitochondrial energy metabolism, decreased oxidative stress, and improved memory . Interestingly, co-supplementation of ALCAR and alpha-lipoic acid resulted in even greater improvements than either compound administered alone.

FLAVONOIDS Because flavonoids have anti-inflammatory, antioxidant

and metal-chelating properties, scientists are interested in the neuroprotective potential of flavonoid-rich diets or individual flavonoids. At present, the extent to which various dietary flavonoids and flavonoid metabolites cross the blood-brain barrier in humans is not known. Although flavonoid-rich diets and flavonoid administration have been found to prevent cognitive impairment associated with aging and inflammation in some animal studies, prospective cohort studies have not found consistent inverse associations between flavonoid intake and the risk of dementia or neurodegenerative disease in humans

DIETARY RECOMMENDATIONS

Following careful nutritional assessment, guidelines have been developed to improve and maintain nutritional status in community-dwelling and hospitalized elderly patients. For example, the Canada Food Guide recommends the following daily nutritional intake for adults:

5–12 servings of grains 5–10 servings of fruits and vegetables 2–4 servings of milk products 2–3 servings of meat or meat alternatives Foods high in fibre and complex carbohydrates such as

whole grains, vegetables, and fruits are preferred. Fat intake should be less than 30% of total caloric intake

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A food pyramid for the elderly

Calcium, vitamin D, vitamin B12, Wholemeal

Fruit 2 portions

Cereals and tubers 6 portions

Wholemeal is better

Vegetables 3 portions

Milk, yogurt, cheese 3 portions

Sweets and fats in moderation

Fish meat legumes 2 portions

Water and liquids 8 glasses

EFFECTS OF AGING ON NUTRITION Changes Effects Sensory Impairment –Decreased sense of taste ÎReduced Appetite –Decreased sense of smell ÎReduced Appetite –Loss of vision and hearing ÎDecreased ability to purchase and

prepare food –Oral health / dental problems ÎDifficulty chewing,

inflammation, poor quality diet Altered energy need ÎDiet lacking in essential nutrients Decreased physical activity ÎProgressive depletion of LBW and

loss of appetite Muscle loss (sarcopenia) ÎDecreased functional ability,

assistance needed with ADLs.

ASSESSING NUTRITIONAL STATUS

A comprehensive assessment of nutritional status includes anthropometric measurements,

laboratory values, physical exam, and patient history. Anthropometric measures include

height, weight, body mass index, body fat measurement, muscle mass measurement, and

body mass index. Laboratory values should include albumin, retinal-binding prealbumin, transferring, complete blood count, serum folate, vitamin B12, and cholesterol. A diet history is helpful if there is good 24-hour recall

or a food record for 3 days leading up to the exam can be completed.

the Mini Nutritional Assessment is a basic screening tool.

PREVALENCE OF MALNUTRITION IN THE ELDERLY

Malnurished At risk Normally nourished

Nursing home 14% 53% 33%

Hospitalized 39% 47% 14%

Rehablitation 50% 41% 9%

Community 6% 32% 62%

PREVALENCE OF MANUTRITION IN THE ELDERLY

1 of 4 of older adults are malnourished. 2 of 4 of older adults are risk of

malnutrition.

POSSIBLE CAUSES OF UNINTENTIONAL WEIGHT LOSS:

M Medications E Emotional Problems A Anorexia Nervosa L Late‐life Paranoia S Swallowing Problems Oral Factors (cavities poorly fitting dentures) N No Money W Wandering and Other Dementia Related Behaviors H Hyperthyroidism, Hypothyroidism E Enteric Problems (malabsorption) E Eating Problems (inability to feed self) L Low Salt, Low Cholesterol Diets S Shopping, Social Problems

WEIGHT LOSS Weight loss in the elderly is a worrisome clinical

sign. Weight loss in the elderly due to voluntary or involuntary causes has been associated with mortality (Himes 1999; Newman et al 2001; Baldwin et al 2002). Although lean body mass may decline because of normal physiological changes associated with age (Lissner et al 1991), a loss of more than 4% per year is an independent predictor of mortality (Wallace et al 1995). Rapid weight loss of 5% or more in one month is considered significant and needs to be immediately evaluated by a physician (Jensen et al 2001; Dryden et al 2002). It has been shown that even moderate declines of 5% or more over three years is predictive of mortality in older adults (Newman et al 2001). However, early identification, assessment, and treatment of weight loss and nutritional deficiencies may prevent the morbid sequel of malnutrition.

WEIGHT LOSS

Functional, psychological, social, and economic issues associated with concomitant medical problems may all contribute to poor nutrition and weight loss in the frail elderly patient (Bartali et al 2003). A multidisciplinary geriatric assessment can be helpful to fully address all the complex interacting issues of the frail senior, such as Mrs E, who experiences rapid weight loss as a result of malnutrition. This type of comprehensive assessment may include the services of physicians, nurses, dieticians, occupational and physical therapists, speech and language pathologists, and social workers, each of which can lend their respective expertise to the effective diagnosis of the functional, psychological, and socioeconomic contributors to malnutrition in older patients.

AGEING AND OBESITY 1. Cardiac disease2. Tumours3. Cerebrovascular diseases4. Chronic pulmonary disease5. Diabetes mellitus

NUTRITIONAL ISSUES ASSOCIATED WITH COGNITIVE IMPAIRMENT AND VASCULAR RISK FACTORS

Malnutrition has been associated with compromised cognitive capacity in the elderly. The decreased ability to prepare a meal, which may adversely affect an elderly patient's ability to ensure sufficient nourishment, has been cited as one of the earliest signs of mild cognitive impairment (MCI), a pre-Alzheimer disease condition (Borrie et al 2003). For persons with moderate to severe Alzheimer disease, forgetting to eat, inability to access food, and apraxia with utensils may further impair oral intake. Living alone, as Mrs E does, further compounds the risk of malnutrition.

NUTRITIONAL ISSUES ASSOCIATED WITH COGNITIVE IMPAIRMENT AND VASCULAR RISK FACTORS

Vitamin deficiencies, particularly vitamin B12, B6, and folate, are associated with cognitive impairment (Nilsson et al 2001; Gill and Alibhai 2003; Lehmann et al 2003). Deficiencies in these vitamins are also associated with hyperhomocysteinemia, which is an independent vascular risk factor. The association of hyperhomocysteinemia with vascular disease is a direct dose-response association (Stamphler et al 1992;Selhub et al 1995). Treatment with folate, vitamin B6, and vitamin B12 has been shown to reduce homocysteine levels (Omran and Morley 2000; Nillson et al 2001; Lehmann et al 2003; Scott et al 2004), improve vascular function in hyperhomocysteinemic patients with coronary artery disease (Willems et al 2002), and result in cholesterol plaque regression (Marcucci et al 2003

Although a recent secondary prevention randomized controlled trial failed to demonstrate a decrease in morbid vascular outcomes in stroke patients following supplementation with vitamins B6, B12, and folate over two years, it was suggested that confounding factors (such as the initiation of folate fortification in grain supply concurrent with the study) might explain the null findings (Toole et al 2004). More research is needed to clarify the complex interactions between these vitamins and the modification of vascular risk factors.

Nutritional interventions have an impact on vascular disease prevention. It is well established that a diet low in fat and cholesterol is beneficial to modifying vascular risk factors. Emerging research suggests that supplementation with omega-3 fatty acids (such as those found in salmon and other cold-water fish), and consuming cruciferous vegetables (such as broccoli, cabbage, and cauliflower) are all associated with stroke prevention (Joshipura et al 1999; Mozaffarian et al 2005; Robinson and Maheshwari 2005) and may be beneficial if integrated into the diet of all elderly patients with vascular disease or vascular risk factors.

Nutritional antioxidant supplements are generally believed to be beneficial in reducing free radical cellular and DNA damage. A large epidemiological study found the concomitant use of vitamins C and E is associated with reduced incidences of Alzheimer disease (Zandi et al 2004). More generally, according to a randomized controlled trial, low blood vitamin C concentrations are strongly predictive of mortality in patients aged 75–84 years (Fletcher et al 2003). The efficacy of vitamin E in the prevention and treatment of MCI and Alzheimer disease remains controversial. Used alone in a three-year placebo-controlled study, a daily dosage of vitamin E (2000 IU) was not shown to slow the rate of progression to Alzheimer disease in patients with MCI (Petersen et al 2005). A high-dose vitamin E supplementation (>400 IU/day) has been associated with increased mortality (Miller et al 2005).

Other important antioxidants with possibly beneficial outcomes include foods with high levels of phytochemicals and flavonoids. Tomatoes, citrus fruit, blueberries, and certain spices (Fusheng et al 2005) have all been linked to reducing oxidative stress and cognitive impairment. Flavonoids and antioxidants in red wine have also been shown to be beneficial in protecting against dementia (Zuccalà et al 2001; Truelson et al 2002). The increasing amount of research in this field holds promise for preventive nutritional strategies based on the benefits of naturally-occurring antioxidants.

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ANTIOXIDANT FOOD WHEEL

VEGETABLES

BREAD CEREALS AND POTATOES

COCOA

PULSEs

NUTS AND DRIED FRUIT

OLIVE OIL

FRUIT

S.E.N.E. C.A. 2007

A good diet should contain antioxidants: vitamin C, vitamin E, polyphenols.

Vitamin C and E make your immune system more efficient(de la Fuente et al. 1998).

“We age because we oxidise (rust)” and anti-oxidants can mitigate the signs of ageing(Miquel et al. 2002).

POTENTIAL CONSEQUENCES OF MALNUTRITION

Impaired immune response Reduced muscle strength and fatigue Inactivity Impaired temperature regulation Impaired wound healing Impaired ability to regulate fluid and

electrolytes Impaired psycho‐social function

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DIET AS ENERGY

The diet should be the source of energy for all daily activities.

Breakfast or lunch should be the highest-energy meals of the day, in order to complete the most important activities.

Dinner should be the least energetic meal of the day, because few activities are done after dinner.

Meals (breakfast in particular) should not be skipped.

The diet should provide calories according to the needs of each individual.

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WOMENLITTLE PHYSICAL ACTIVITY: 1.600 CALORIESMODERATE PHYSICAL ACTIVITY: 1,800 CALORIESACTIVE LIFESTYLE: 2,000-2,200 CALORIES

MENLITTLE PHYSICAL ACTIVITY : 2.000 CALORIESMODERATE PHYSICAL ACTIVITY : 2.200-2.400 CALORIESACTIVE LIFESTYLE : 2,400-2,800 CALORIES

How many calories after the age of 50?

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FOODS RECOMMENDED AS A SOURCE OF EACH NUTRIENT

PROTEIN: meat, fish, eggs, milk products, pulses (chickpeas, lentils).

CARBOHYDRATES: bread, rice, pasta, potatoes, pulses.

FATS: olive oil, oily fish, nuts, dried fruit.

VITAMINS: fruit and vegetables, olive oil.

MINERALS: milk products, nuts and dried fruits, fish, cereals.

FIBRE: fruit, vegetables, wholemeal products.

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Cereals and tubersCEREALS: RICE, BREAD, PASTA, CORN, WHEAT, BARLEY, SPELT AND TUBERS (EG. POTATOES) ARE THE PRINCIPAL SOURCE OF ENERGY.

IT IS ADVISEABLE TO USE, AT LEAST SOMETIMES, WHOLEMEAL PRODUCTS. THESE CONTAIN PROTEIN AS WELL, AND ARE RICHER IN MINERALS AND VITAMINS.

AMOUNT PER DAY: 6 PORTIONSONE PORTION, FOR EXAMPLE: HALF A PLATE OF PASTA OR RICE, A SANDWICH, A BOWL OF CEREAL

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Fruit and vegetablesFRUIT AND VEGETABLES CONTAIN VITAMINS, FIBRE AND WATER AND MINERAL SALTS.ALIMENTARY FIBRE HELPS YOU TO FEEL MORE FULL AND REDUCE THE RISK OF TUMOURS, DIABETES, AND HEART DISEASE.

CHOOSE FRESH SEASONAL OR FROZEN VEGETABLES.IT IS BEST TO STEAM THEM OR COOK THEM IN A PRESSURE COOKER WITH VERY LITTLE WATER.

DAILY AMOUNT:3 PORTIONS OF VEGETABLES 2 PORTIONS OF FRUIT

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Meat, fish and eggsTHESE ARE FOODS RICH IN PROTEIN WITH A HIGH BIOLOGICAL VALUE, WITH MINERALS AND B VITAMINS.

LEAN MEAT AND FISH ARE PREFERABLE.

IT IS BEST TO GRILL THEM, STEAM THEM, OR COOK THEM WITH VERY LITTLE FAT

DAILY AMOUNT:2 PORTIONS

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Milk, yogurt and cheese

MILK AND MILK PRODUCTS (CHEESE, YOGURT) PROVIDE CALCIUM, PROTEIN AND SOME VITAMINS.

IT IS ADVISABLE TO USE, AT LEAST PARLY SKIMMED, LOW-FAT PRODUCTS.

DAILY AMOUNTS:3 PORTIONS

ONE PORTION, FOR EXAMPLE: 50G OF CHEESE, A GLASS OF MILK OR 1 YOGHURT (100 GR)

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Limit animal fats CHOOSE LEAN MEATS, FISH OR POULTRY (WITHOUT THE SKIN)

REMOVE THE FATTY PARTS BEFORE COOKING

USE LOW-FAT PRODUCTS

USE LITTLE FAT FOR COOKING

CHOOSE VEGETABLE FATS (EXTRA VIRGIN OLIVE OIL)

AVOID FRIED FOOD

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HYDRATION

Water does not give energy, but is fundamental for hydration.

Sugar-free fruit juice, milk and soups can also help with hydration.

The daily dose of liquids should be 1 and a half or two litres.

Fruit and vegetables are a good source of water.

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VARIETY AND BALANCE: THE KEY TO A GOOD DIET

At every meal: protein, carbohydrates, fats, vitamins, liquids and fibre in adequate proportions.

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KEY POINTS

• Avoid chilled, pre-cooked or re-heated meals• Break our food down into three meals and two

snacks. • Have a good breakfast with milk or yogurt.• Choose food according to the action necessary to

eat it (cut, grind, squash, etc).• Keep to a good body weight and a good level of

physical activity.• Drink water frequently during the day.• Chew each mouthful well before swallowing.

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Tasty and varied food with aromatic herbs and spices Avoid the consumption of animal fats Eat more fish (especially oily fish) Eat more food rich in complex carbohydrates, fibre,

vitamins and minerals (fruit, vegetables, pulses and wholemeal products)

Sugar: is obtained from fruit and milk Wine: in moderation (1-2 glasse per day); avoid spirits Salt: limit what you add at the table

Key Points (2)

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Divide participants into 3 groups:

Each participant fills in his or her food diary

They swap diaries with others in the group and analyse the diaries, classifying 3 of their choices as healthy, and 3 as unhealthy.

Among all the group members the most interesting case is selected to be discussed in the plenary.

PRACTICAL ACTIVITIES

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MY DAILY FOOD HABITSTIME 6 8 10 1

216

18

20

22

24

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SELECTION Write in the two columns:

HEALTHY FOOD HABITS UNHEALTHY FOOD HABITS

Write at least four items

CASE 1

Mrs E is a 79-year-old female with Alzheimer-type dementia living alone in her own home with assistance only for heavy housework. She has maintained her weight for one year while taking a cholinesterase inhibitor. She sees her family doctor every 6 months. Her most recent check-up revealed a weight reduction of 3 kg from her previous visit. Patient height 160 cm; weight 48 kg [BMI=19 kg/m2].

Mrs E has lost 6% of her body weight in six months. This is a cause for concern. Her physician needs to consider causes for weight loss such as new hyperthyroidism, diabetes, malignancy, depression, or oral problems. These can be ruled out by history, physical examination, and laboratory tests. Collateral history from family or caregivers is very important in assessing a person with dementia. Patients with dementia often have an atypical presentation of many illnesses in the elderly, especially in cases of depression.

A medication review is also an important part of the physician's assessment of this patient. For example, cholinesterase inhibitors as a class can cause nausea, vomiting, anorexia, or diarrhea and can be associated with weight loss. In Mrs E's case, she was able to maintain her weight for a year on this medication. For this reason, other causes of weight loss associated with dementia should also be considered. For example, the loss of caregiver support, social isolation, limited access to food, an inability to cook and prepare food because of cognitive problems, or inability to recognize hunger may contribute to her current malnutritive state. Collateral history from a caregiver and a home visit can provide invaluable insight into these issues. Home care nurses or occupational therapists can assist in this assessment.

A nutritional treatment plan for Mrs E may include the treatment of any newly diagnosed medical issues and the prescription of nutritional supplements. In this case, considering a referral to social and community programs (such as adult day care, home care services, or a delivered meal program) would be appropriate at Mrs E's discharge.

CASE 2

Mrs A is an 82-year-old female living alone, independent in her activities of daily living, and instrumental activities of daily living2. She has a history of non-insulin-dependent diabetes mellitus requiring insulin, hypothyroidism, osteoarthritis, hypertension (HTN), ischemic heart disease (IHD), obesity, and gastroesophageal reflux disorder (GERD). Mrs E recently suffered a hip fracture following a fall for which she underwent a hip-replacement surgery. Her postoperative course is complicated by a urinary tract infection (UTI) and two episodes of clostridium difficile (C. difficile) colitis. She was transferred to a geriatric rehabilitation unit. Patient height 160 cm; weight 94 kg [BMI = 37 kg/m2].

Mrs A's situation is complex and highlights some of the issues of nutritional assessments in the hospital setting. A physician is needed to immediately address Mrs A's other underlying medical problems such as obesity, IHD, GERD, and HTN, prior to her general nutritional assessment by a dietician. Diabetes can be a major issue during her hospital stay. Another possible nutritional issue associated with diabetes is substantial proteinuria brought on by diabetic renal disease. Sequelae of diabetes include autonomic dysfunction, which can result in delayed gastric emptying and poor oral intake. This condition can be exacerbated by the use of narcotics to control postoperative pain, and is further compounded by GERD. Infection and obesity often increase insulin resistance, so blood sugar control should be optimized not only for the long-term morbidity prevention, but also for wound healing.

Prior medical complications and the medications prescribed following her hip surgery are another cause for concern. Mrs A may have had poor oral intake because of her diarrheal illness, or from the side effects of antibiotics used to treat C. difficile arising from her UTI. Many elderly hip fracture patients have muscle deconditioning as a result of being hospitalized and consequently require increased protein supplementation. Serum prealbumin or albumin is usually used to assess nutritional status and monitor improvement through a hospital stay. Although Mrs A is obese with a BMI of 37 kg/m2, she likely has a low albumin level and significant protein undernutrition based on her recent medical history. One complication in the treatment of obese patients is the provision of adequate calories and protein for wound prevention and treatment, muscle reconditioning, and therapy-related exercise while concurrently promoting a loss of total body fat. Generally speaking, achieving an optimal balance of food intake, nutritional status, and healthy body weight is a particular challenge for health practitioners (Sullivan et al 2004), particularly when treating patients with extremely high or low BMI measurements.

Finally, Mrs A's HTN and obesity suggest additional risk factors for ischemic heart disease. Her cholesterol profile prior to her hospitalization would provide additional information in planning long-term nutritional goals at discharge. Sodium, fat, and cholesterol restrictions may be appropriate. Other nutritional goals during Mrs A's hospital stay should include ensuring that she has adequate education to both understand and follow her dietary advice. Referral to a community dietician or diabetic educator is recommended in Mrs A's discharge planning.

CASE 3

Mr T is an 83-year-old male who has been living in a nursing home for the past 12 months since suffering a right middle cerebral artery stroke. During this time he has had trouble feeding himself and has lost 10 kg. He has a coccyx ulcer. Patient height 180 cm; weight 55 kg [BMI= 17 kg/m2].

Mr T has severe malnutrition with a BMI of 17 kg/m2 and a corresponding high risk of morbidity and mortality. Given his acute nutritive needs following his medical history of stroke (Dennis et al 2005), Mr T's nutritional assessment and treatment plan should include a physician, dietician, speech and language pathologist, and an occupational therapist.

The benefits of stroke rehabilitation are well documented (Gresham et al 1997). One of the first treatments often recommended immediately following a stroke is a swallowing assessment and, if necessary, training to facilitate improved swallowing. For patients who require tube feeding, it has been determined that patients with significant dysphagia who undergo gastronomy tube feeding have less risk of aspiration, earlier discharge from hospital, and higher albumen levels with gastrostomy tube feeding than those who undergo nasogastric tube feeding (Milne et al 2005). Early tube feeding following stroke has been associated with decreased mortality in older patients (Dennis et al 2005).

It is likely that Mr T had the appropriate assessment in hospital following his stroke. Nevertheless, a bedside swallowing assessment performed by a speech and language pathologist is very helpful in determining the type of food consistency that is appropriate in a person with dysphagia. Sometimes it is necessary to refer the patient for a modified barium swallow to further assess their risk for aspiration. Furthermore, positioning and seating are important requirements for successful meals. Occupational therapists can assist with this as well as the provision of special utensils, plates, or placemats in order to better facilitate self-feeding.

A number of other possibilities may contribute to Mr T's current condition. For example, Mr T may have extended his stroke resulting in worse dysphagia and subsequently decreased oral intake. Untreated dysphagia may result in protein undernutrition, which can result in compromised immunity and an increased risk of infection (Hudson et al 2000). He may have developed post-stroke depression, which often manifests a decrease in appetite. It is possible that not all of the dietary recommendations of the stroke team were followed after discharge. Sometimes this is because of patient choice; for example, a common recommendation involves restricting patients' diet to pureed foods. Some patients assess the relative risks (which include aspiration) and prefer a diet with varied textures as a quality of life consideration. Nutritional deficiencies have been suggested, but not clinically confirmed, to adversely affect vascular outcomes in stroke (Toole et al 2004).

Mr T needs a comprehensive physical and cognitive examination, and laboratory tests to exclude new medical problems as contributing causes for his weight loss. Since protein undernutrition and low vitamin C levels are associated with poor wound healing and pressure sores, a dietician should participate in Mr T's treatment plan and consider supplementation in vitamin C, zinc, and other trace minerals, in addition to increased caloric and protein intake. His albumin level should be regularly measured to provide objective monitoring of the treatment plan.

KEY POINTS

Age-related changes in physiology and immunity may result in a greater need for vitamin and mineral supplementation in the elderly.

Dietary modifications, such as including foods high in antioxidants and lowering intake of fat and cholesterol, may improve cognition and modify vascular risk factors in elderly patients.

KEY POINTS

Hospitalized elderly patients are at particular risk for malnutrition and need to be carefully assessed and aggressively treated.

There are several effective and easy-to-use screening tools which assess for malnutrition in elderly patients. The most extensively validated tool is the Mini Nutritional Assessment (MNA), which provides an accurate assessment of elderly patients from a variety of domiciliary settings.

KEY POINTS

Dietary assessment and counseling comprise an important and effective aspect of preventing and treating a variety of morbid conditions in elderly patients.

TAKE HOME MESSAGE Multivitamin supplements are highly recommended for older patients,

especially in seniors whose daily caloric intake is less than 1500 kcal/day. Advise patients about nutrient-dense food choices when appropriate. Investigate body weight losses of 4% or more. Nutritional supplements are recommended for at-risk elderly hip fracture

patients. Also consider supplements for frail seniors with other fractures. Calcium and vitamin D supplementation have been shown to reduce hip

fracture rates and are recommended for patients over 65 years of age. Advise patients on the merits of whole grains, fruits, and vegetables. In hospitalized patients, maintain a high index of suspicion for pre-existing

nutritional deficiencies. Utilize the services of a registered dietician. Consider referrals to other health professionals for nutritional advice such as

dieticians, speech and language pathologists, homecare or visiting nurse services, or other specialized geriatric services available in the community.