Chapter 19

Nutrition and Older Adults:Conditions and Interventions

Introduction: The Importance of Nutrition

• Aging adults want to stay healthy until death

• Chronic illnesses are more prevalent in old age

• Having a chronic health problem does not prevent someone from having the perception of being healthy

Introduction: The Importance of Nutrition

• Good nutrition can ameliorate effects of illness & contribute to quality of life– Quality of life—measure of life satisfaction on

factors such as social contacts, economic security, & functional status

• Outcome data on effectiveness of MNT has resulted in Medicare reimbursements to people with diabetes & kidney disease for MNT services

Nutrition and Health

• Adults of all ages have defined health as “a sound mind in a sound body”

• Health is monitored by measuring– leading causes of death (mortality) – leading diagnoses of health conditions

(morbidity)

• Interventions are designed to improve the population’s health.

Nutrition and Health

• Deaths from heart & cerebrovascular diseases have declined by 2% and 1% (since the last edition of the text)

• Diet impacts many chronic conditions• Leading causes of death for those ≥65:

– Heart disease – Cancer – Respiratory disease – Cerebrovascular disease – Alzheimer’s– Diabetes

Heart DiseaseCHD/CVD/PAD

• Heart disease—potentially reversible by adopting a healthy lifestyle

• Prevalence– Varies by race and gender (See Table 19.2)

• Risk factors– Hypertension (≥140/90 mmHg) LDL cholesterol (≥130 mg/dL)– Diabetes – Race (African Americans)

Nutritional Remedies for Cardiovascular Disease

• Assertive treatment can modify the course of heart disease at any age.

• Older adults may have more comorbid conditions.

• Nutrition interventions are not inherently different for older or younger adults.

• Age related considerations are in Table 19.3.

Treatment Factors for Older Adults with Heart Disease

Stroke: Definition & Forms

• Stroke– Serious conditions involving reduced cerebral blood flow

(brain ischemia)

– Ischemia—blockage of blood vessel lack of blood supply

– Aneurysm—ballooning of the blood vessel wall– Thrombus—blood clot– Cerebral embolism—wandering blood clot (embolus)

lodges in artery & blocks blood flow to brain

Stroke: Definition & Forms

• Definitions– Carotid Artery Disease—arteries that supply

blood to the brain and neck become damaged– Atrial Fibrillation—degeneration of the heart

muscle causing irregular contractions– Transient Ischemic Attacks (TIA)—temporary

and insufficient blood supply to the brain

Stroke: Prevalence & Etiology

• Prevalence– Of adults ≥65, 8% of females & 9% of males

have had a stroke

• Etiology– Blocked arteries– Easily clotting blood cells – Weak heartbeat unable to circulate blood

Stroke: Effects

• Effects of strokes include:– Deprivation to brain of oxygen & other

nutrients causing cell death– Loss of speech & ability to walk & eat

• Quick recognition & treatment results in faster treatment & recovery

Stroke: Risk Factors

• Stroke Risk Factors– Age – Long-term high blood pressure– Family history– African American, Asian, Hispanic– Physical inactivity– Cigarette smoking

Stroke: Risk Factors

– Comorbid conditions• Diabetes mellitus • Carotid artery disease• Atrial fibrillation• Sickle cell anemia• Depression • Transient ischemic attacks

– Living in poverty– Excessive use of alcohol; Drug abuse

Stroke: Nutritional Remedies

• The overall goal is to normalize blood pressure

• Other goals include:– Reduce overweight & obesity—mainly

abdominal fat– Moderate alcohol intake– Increasing fruit and vegetables

Hypertension: Definition

• High blood pressure (HBP)-hypertension (HTN)– Blood pressure of ≥140/90 mm Hg

• Prehypertension – Systolic blood pressure for 120-139 and/or – Diastolic pressure of 80-89

Hypertension: Prevalence and Etiology

• Prevalence in adults ≥65– < 64 yrs-more common in men– > 65 yrs-more common in women– Prevalence increases with age

• Etiology– Family history– African Americans– ~20% of cases linked to salt intake

Hypertension: Effects and Risk Factors

• Effects– Extra tension on blood vessels wearing them

out before natural aging process– Damaged kidneys are common

• Risk factors alcohol consumption saturated fat intake– Overweight & obesity dietary calcium

Hypertension: Nutritional Remedies

• 2 main strategies:– Maintaining healthy weight– Reducing sodium to <1500 mg/d

• Other recommendations– Moderation in alcohol– Adequate potassium, magnesium, & calcium

intakes– Following MyPlate & DASH guidelines

The DASH Eating Plan for Blood Pressure Control

Diabetes

• Special Concerns for older adults

• >risk for heart disease

• Risk for atherosclerosis

• Several comorbid conditions

• Prevalence

• ~20% of ≥65

• Diagnostic criteria same as for younger adults

Diabetes

• Effects of diabetes– Amputations– Macular degeneration– Visual loss– Cataracts– Glaucoma– Neuropathies

• Hyperglycemia– Sodium depletion &

dehydration– Trace mineral

depletion– Insomnia, nocturia,

blurred vision

• Hypoglycemia– Weakness and

confusion

Other Considerations for Diabetes Intervention

– Health goals similar to USDA guidelines

– Individualize diet recommendations to individual’s personal needs & preferences

– If nephropathy is present, limit protein to <1.0 g/kg/d

– Assess dietary adequacy & supplement with vitamin/mineral if needed

– Monitor physical & mental abilities

Other Considerations for Diabetes Intervention

– Ask about special foods and alternative and complimentary therapies

– Safe complimentary nutritional remedies - enhance standard nutritional therapies

– Clarify confusing food terms• i.e. pre- and pro-biotics• Sugar alcohols

– Review CHO and fiber recommendations

Other Possible Interventions for Diabetes

– Jerusalem artichoke—vegetable that contains the fructose polymer inulin (not insulin) - Does not lower blood sugar

– Non-caloric sweeteners—saccharin, aspartame, acesulfame potassium, sucralose

– Sugar alcohols (xylitol & sorbitol)—used to sweeten sugar-free candies

– Pectins & gums—slow glucose absorption & lower cholesterol

Obesity

• Definition – BMI of ≥30.0 – Extreme obesity is BMI ≥40

• Prevalence– Rates in older adults have increased

• Men from 20% to 37%• Women from 24% to 39%

Etiology/Effects/Risk Factors of Obesity

• Fitness contributes more to longevity than absolute weight

• CDC supports lowest mortality is with BMI from 18.5-30

• Extra weight during illness is protective to older adults

Nutritional Remedies for Obesity

• Healthy Eating + Physical Activity

• A healthy eating program based on enough nutrient-dense calories to support slow weight loss

• Adequate physical activity to ensure functional independence

Osteoporosis

• Definition of Osteoporosis– “Porous bone”– Results from bone mass & disruption of

bone architecture

• Prevalence– Higher in women than in men– Less common in Blacks since they have

denser bones– Osteoporosis has no symptoms

Osteoporosis

• Etiology– Low bone density – Increased risk of fractures

– Due to:• Inadequate building of peak bone mass• Significant bone loss

Osteoporosis

• Etiology– Inadequate bone mass resulting from:

calcium intake during ages 11-17• Inactivity (bed rest, sedentary life-style)• Weight-bearing or resistance exercise are needed

to develop bone mass• Bone mass grows in response to pressure on bone

tissue

Osteoporosis

• Etiology– Increased bone loss linked to:

blood calcium that PTH intake of Ca, Mg, Ph, Fl, Bo, & vit D & K weight-bearing activity• blood Ph Ca release from bones• The process of normal aging results in slow

increase of PTH and decrease in skin’s ability to make Vitamin D=bone loss

Osteoporosis

• Falls and fractures– Of older people who break a hip:

• 10-20% die within a year• 50% have permanent disabilities

• Shrinking height, Kyphosis– ~67% of vertebral fractures are asymptomatic– Results from compression and/or bone

fracture in spine

Risk Factors for Osteoporosis

• Risk factors grouped as – Not modifiable factors – Potentially modifiable factors– Controversial factors (Not yet clear)– see Table 19.8

Risk Factors for Osteoporosis

Nutritional Remedies for Osteoporosis

• Nutritional remedies:– adequate calcium; absorption

• Calcium and vitamin D through diet or supplements

• don’t take calcium with antacids• consume foods rich in vitamins C, D, B6

and K, which help build bones

Example of 1 Day’s Food that Provides 1200 mg Calcium

Dietary Components that Contribute to Calcium in Urine

Other Issues Impacting Nutritional Remedies

– Hormones—HRT does bone minerals, but puts women at risk of breast cancer, CHD, stroke & thromboembolism

– Exercise—does bone mass– Medications—Serotonin reuptake inhibitors

(SSRIs) —Associated with bone loss

Other Issues Impacting Nutritional Remedies

– Summary– Best prevention strategy:– Exercise & adequate diet in young people– Nutrient dense diet, supplemented with

calcium– Vitamin D and appropriate exercise in older

adults

Older People Reporting Having No Natural Teeth

Nutrition and Oral Health

• Terms related to oral health– Xerostomia—dry mouth– Dysgeusia—loss of taste– Glossodynia—pain of the tongue

Nutrition and Oral Health

• Good oral health for older adults– Brushing and flossing– Dietary recommendations (same as younger

adults)– Tea sippers may have advantage

• Polyphenols in black tea interfere with bacteria’s ability to stick to plaque

• Swishing with tea does not take the place of brushing and flossing

Gastrointestinal Diseases

• Parts of the GI Tract Most Likely to Malfunction– The esophageal-stomach juncture: weakened

muscle results in GERD– The stomach: acidity leading to changes in

nutrient absorption; or acidity causes ulcers

– The intestines: resulting in constipation, diarrhea, & some food intolerance

Gastroesophageal Reflux Disease (GERD)

• Definition– Occurs when stomach contents flow back

into the esophagus

• Prevalence– 25-35% of adults

• Etiology and Effects– Caused by either:

• LES weakened by acid• A weakened sphincter

Gastroesophageal Reflux Disease (GERD)

• Nutritional risk factors– Alcohol– Obesity– Smoking– Coffee (regular & decaf)

Gastroesophageal Reflux Disease (GERD)

• Nutritional remedies– Omit foods that cause discomfort—varies

from person to person

– General guidelines• Low-fat diet• Avoid large meals• Remain upright after eating

Changes in Nutrient Absorption: Vitamin B12 Deficiency

Changes in Nutrient Absorption: Vitamin B12 Deficiency

• Two types of vitamin B12 deficiency:

– Pernicious anemia—due to lack of the intrinsic factor

– Food-bound malabsorption, often due to hypochlorhydria

Pernicious Anemia

• Definition and effects– Caused by lack of intrinsic factor which

prevents B12 absorption

• Symptoms:– Large, undeveloped RBC– Glossitis– Tongue fissures– Irreversible neurological symptoms

Pernicious Anemia

• Prevalence– Uncommon, even in older adults– Takes 3-6 yrs to develop

• Risk factors– History of Helicobacter pylori stomach acid– Family history

• Nutritional remedies– B12 given by injections or synthetic given orally

(unbound to protein)

Vitamin B12 Malabsorption

• Definition and etiology– Most commonly results from abnormal stomach

function such as bacterial overgrowth– B12 is not digested, absorbed, or bacteria may

use B12 for own metabolism • Prevalence

– Estimates range from 1-46% of the population• Effects

– Irreversible neurological damage, walking & balance disturbances

Constipation

• Definition—no one definition

• Prevalence—depends on definition

• Etiology— muscle strength, chewing problem, fiber, etc.

• Effects—possible diverticulitis

Constipation

• Risk factors— fluid intake amounts of food– Medication– Iron supplements

• Nutritional remedies dietary fiber & fluids

Inflammatory Diseases: Osteoarthritis

• Etiology—– cartilage loss– bone hypertrophy – changes in the synovial membrane– hardening of soft tissues & inflammation

• Effects of osteoarthritis – Pain with joint movement

Inflammatory Diseases: Osteoarthritis

• Risk factors– Obesity– Joint injuries– Continuous exposure to oxidants– Possibly vitamin D

• Nutritional Remedies– Wt loss is 1st treatment

Other Nutritional Remedies for Inflammatory Diseases

• Nutritional remedies for inflammatory disease– Antioxidants– Vitamin D– Flavonoids– Chondroitin – Glucosamine– Vegetarian diets

Cognitive Disorders: Alzheimer’s Disease

• Alzheimer’s disease definition– Dreaded aspect of “getting old”– Loss of independent functioning– Memory impairment– Dementia

Cognitive Disorders: Alzheimer’s Disease

• Dementia—a progressive cognitive decline, characterized by impaired thinking, memory, decision-making, & linguistic ability

• Symptoms associated with dementia include:– Alzheimer’s disease– Vascular dementia– Parkinson’s disease– Alcohol-related & AIDS-related dementia

Prevalence of Dementia

• In the U.S.– 14% of older adults have dementia– ~10% have Alzheimer’s disease (AD)

• Prevalence with age

• AD ranks 5th in leading cause of death for adults >65 years

Effects of Cognitive Disorders

• Effects of cognitive disorders– Confusion– Anxiety– Agitation– Loss of oral muscular control– Impairment of hunger/appetite regulation– Changes in smell & taste– Dental, chewing, & swallowing problems

Effects of Cognitive Disorders

• Nutritional Interventions for Cognitive Disorders– Ensuring food safety– Safe use of kitchen tools and equipment– Dietary focus

• Nutrient-dense diet• Maintain hydration• Supply needed energy

Effects of Cognitive Disorders

• Nutritional Interventions for Cognitive Disorders

• Strategies to promote food and fluid intake– Maintain focus on eating– Provide plenty of time to eat– Serve finger foods– Encourage regular drinks between bites

Polypharmacy

• Polypharmacy (taking several different drugs each day) – Increases with age – Associated with adverse drug reactions– Hospital admissions/readmissions– Increased mortality

• Effects of Medications• Medications may require dietary restriction & can

interfere with appetite, digestion, & metabolism

Low Body Weight/Underweight

• No consensus or universal definition for underweight in the frail elderly

• Compare current weight to “usual” weight

• Grades of Thinness– Grade 1 = BMI 17-18.49– Grade 2 = BMI 16-16.99– Grade 3 = BMI <16

Etiology of Low Body Weight/ Underweight

• Etiology– Not problematic if person has always been thin– Weight cycling is problematic– In older adults, underweight is more serious than

overweight– Protein-calorie malnutrition leads to underweight– Underlying causes

• Illness• Poverty• Functional decline

Nutrition Interventions for Low Body Weight/Underweight

• MNT for a frail, elderly, malnourished person should consider:– Calories eat & exercise to build muscle

mass & strength– Protein 1 to 1.5 g/kg– Water 1 mL/kcal, rehydrate slowly

Dehydration

• Definition of dehydration– Physiological state in which cells lose water to the

point of interfering with the metabolic processes– Seven signs & symptoms

• Upper-body muscle weakness• Speech difficulty• Confusion• Dry mucous membranes (nose/mouth)• Longitudinal tongue furrows• Dry tongue• Sunken appearance of eyes in sockets

Dehydration

• 3 types of dehydration:– Isotonic– Hypotonic– Hypertonic

• Related to proportional balance of sodium and water losses

• Dehydration can be measured as % of body weight loss.

Dehydration

Effects of Dehydration

• Effects– Increases resting heart rate– Susceptibility to development of urinary tract

infection– Pneumonia– Pressure ulcers– Confusion, disorientation, dementia

Nutritional Interventions for Dehydration

• Beverages Contribute Nutrients + Fluid

• Tea has flavonoids (antioxidants)

• Milk has calcium, protein, riboflavin, & vitamin D

• Cranberry juice may reduce UTI

• Fruit & vegetable juices count toward fruit & vegetable servings

Rehydration

• Rehydrate slowly– Guidelines

• Provide 1/4 to 1/3 overall fluid deficit• Use water of 5% glucose solution• Thickened liquids count as fluid• Offering fluids hourly and with medication –

achieve higher levels of hydration

Rehydration

• Dehydration at end of life ~ overall slowing down of body systems

• Decreased body fluids• Patient may have dry mouth that can be

alleviated by ice chips

Bereavement

• The loss felt when someone who is personally significant dies

• Occurs more in lives of older people

• May negatively impact eating

• Stages: – shock & denial, disorganization, volatile

reactions, guilt, loss & loneliness, relief, & reestablishment