Nutrition in Older Adults with voice overs


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Nutrition lecture given for HRSA Comprehensive Geriatric Education Classes at all 4 Piedmont Hospitals 2009-2012.

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  • Malnutrition may be present in persons who are overweight. You are considered overweight if your BMI is greater an 25, and considered obese if your BMI is greater than 30. Of men aged 75 years and older, 56.5% could be considered overweight, and 13.2% are obese. Among older women, 52.3% are overweight and 19.2% are obese
  • We are going to focus on hospitalized older adults: Actually med surg pts nutritional status actually tends to worsen during a hospitalization Just how important is nutrition during a hospital stay? The prevalence of protein-calorie malnutrition among independent living older adults is 1% to 15%; it is up to 85% in institutionalized patients, and 35% to 65% in hospitalized older patients.[1] Nearly 50% of persons aged 65 years and older are clinically malnourished at the time of admission to a hospital, and two-thirds are malnourished at the time of discharge. In the US, an estimated 31% of males and 61% of females aged 65 years and older have annual incomes of $10,000 or less, which impacts adversely on their access to food and food choices. Among those 75 years old and older, an estimated 40% of men and 30% of women are at least 10% underweight. This means that their Body Mass Index (BMI) is low. Approximately 16% of noninstitutionalized older Americans consume less than 1,000 kcal per day.
  • LOS increases by 90% Hospital charges can be as much as 75% higher As it weaken the respiratory muscles – leads to respiratory infections Protein calorie malnutrition, type most often in these pts, results in skeletal muscle wasting- then decreased strength and falls
  • medications that bind to protein will then have higher levels – thus standard dose can actually be at toxic levels : think dilantin, coumadin
  • With aging, independent of disease or dietary deficiency, there is a progressive loss of lean body mass , amounting to about 10 kg in men and 5 kg in women. It accounts for the decrease in BMR, a total body weight, skeletal mass, and height and for the increase in mean body fat (as a percentage of body weight) from about 20% to 30% in men and from 27% to 40% in women. These changes and a reduction in physical activity result in lower energy and protein requirements compare with those of younger adults. Disease, stress, injury, and chronic drug use can all increase an older adult’s nutritional needs. Chronic issues such as cardiac and COPD increase the calorie requirements due to increased muscles required for basic function Medications- alter taste, absorption, appetite Lack of exercise and overeating are major factors resulting in increased weight. Data shows Older adults don’t “play catchup” when they miss intake and have wt loss A diminished sense of taste and smell , loneliness , physical and mental handicaps, immobility, and chronic illness can cause inadequate dietary intake in the older adult population. Absorption is reduced, possibly contributing to iron deficiency, osteoporosis (also related to calcium deficiency), and osteomalacia due to lack of vitamin D and the absence of exposure to sunshine. Depression in the older adult can often lead to malnutrition or dehydration, which can induce various kinds of physical illnesses. Physical illness can induce depression in an older adult because of psychological vulnerability. Lack of interest in eating is one of the classic signs of depression in older persons and should always be explored Impaired function may limit their eating ability. For example, if the older adult has aphasia, they cannot express their food preferences, and with agnosia, they may not be able to recognize their eating utensils. Dysphagia is impaired swallowing which may cause malnutrition. They might be unable to use their upper extremities to feed themselves due to tremors, limited strength and poor coordination.
  • Need to know baseline so can evaluate where and what are needs, issues- goes toward the discharge plan Need accurate info for med calculations and determine nutritional needs Measure do not use pt/family reports As we age, nutritional requirements change. Basal energy requirements over time is reduced and this is primarily due to a decrease in lean muscle mass and metabolic rate of this tissue. The older adult’s recommended daily allowance is 30 kcal/kg/day, but they usually do not consume this RDA for various reasons, which we will discuss later, but it is important to perform a nutritional screening. Nutritional Screening, which should be completed within 24 hours of admission, is the process of identifying patients who are malnourished or at nutritional risk. A three-day food diary , with one day being a weekend day, is the best method of obtaining a diet history. Persons regularly underestimate the amount or portion of food they eat. A nutritionist or dietician can individualize an assessment. For community dwelling persons and for rapid screening, use “Determine Your Nutritional Health” screening tool. It is a self-administered, scored checklist aimed at nutritional awareness of the non-institutionalized older adult. Track weights and weight changes. Weight should be measured weekly for older adults at risk , and monthly for others . Height should be measured annually as changes in height may be indicators of osteoporosis. Obtain baseline measurements of height and weight; use a standard scale and tape measure. Do not rely on self-reports of height and weight. Individuals often give data that are more representational of earlier (midlife) values. The Body Mass Index measure estimates total fat stores within the body by relating the height and weight and is a much more sensitive indicator of nutritional problems than weight alone. Calculate a person’s Body Mass Index (BMI) by dividing weight (in kilograms) by height (in meters) squared: A BMI between 22 and 25 indicates good nutritional status. A lower measure suggests undernutrition and malnutrition.
  • Use calorie cts for accurate estimate of calorie and nutrient intake However- if less than 50% eaten off tray- this is a red flag- intervene; NPO for more than a few hours should also raise your concern Can also indicate self neglect, cognitive impairment Fluid intake is related to food intake: if not eating enough then almost sure they are not drinking adequately
  • Physical assessment should focus on: skin turgor, skin lesions (especially pressure and nonhealing ulcers); changes in skin color; thick or brittle hair; muscle wasting; oral status (including loose teeth or poorly fitting dental appliances); state of hydration; oral lesions, hyperplasia of gums, or fissures around lips; enlarged, smooth, or beefy red tongue; poor hygiene. Overweight older adults are prone to many chronic illnesses and functional losses. Serologic parameters to assess include a measurement of certain plasma proteins that reflect the adequacy of
  • Other serologic parameters include: 1.Total protein, which is another indicator of nutrition. But keep in mind that this can be falsely elevated in dehydrated persons. 2.BUN/Creatinine ratio measures hydration and renal function 3.Complete Blood Count – look for signs of anemia and calculate the lymphocyte count, which is another indicator of malnutrition 4.Blood Glucose – for hypo-or hyperglycemic states Further tests/findings include: 1.iron stores ferritin, vitamin B12 and lipids with special attention to hypocholesterolemia as an indicator of a starvation state 2.Dyslipidemia and elevated triglycerides place the obese patient at risk for heart disease and stroke. Performance-based Functional Status must include an observation of the older adult eating assorted types of food at different times of day, and manipulating various types of tableware (e.g. silverware, drinking glasses, cups, mugs, and serving dishes). Note the inconsistencies between the diet reported and the biochemical and physical parameters of older adults. These inconsistencies may indicate food insecurity (inability to obtain or prepare food because of poverty or inadequate cooking or food storage equipment). Lack of congruence may also be indicative of neglect or abuse by caregivers or the inability of caregivers to manage mealtimes.
  • Be familiar with the Modified Food Pyramid for Seniors. As people age, their appetites may decline but their nutritional needs do not. To reflect the changing dietary habits of adults older than 70, researchers at Tufts University USDA Human Nutrition Research Center on Aging, located in Boston, modified the food pyramid for seniors--most notably to include supplemental vitamins. Tufts' researchers recommend seniors supplement with calcium and vitamins B12 and D, because older adults tend to drink less milk and get less sunlight than younger people. In addition, many older people do not properly absorb vitamin B12. Also new to the pyramid is water at its base. Seniors are advised to drink eight or more eight-ounce glasses of water daily to avoid dehydration and constipation, which are common because thirst sensation decreases with age. The pyramid still promotes a diverse diet rich in grains, vegetables and fruit but low in saturated fat, fatty acids and cholesterol. The modified pyramid is narrower overall, though; to reflect seniors' decreased energy needs, while emphasizing nutrient-dense foods and fiber in fewer servings. [1] [1]
  • Why is this more a problem with older pts? Mortality of up to 50% if not treated Risks: Nl aging shift in body composition- have a decrease in total fluid thus less to lose before get in trouble plus kidneys become less able to concentrate urine Meds- diuretics Illnesses v/d Chronic issues- incontinence- patients restrict intake to decrease this! Being in hospital- functional problem of getting to fluids , selection
  • Makes early dx difficult symptoms vague, deceptive, absent
  • Look for tongue and mucus membrane dryness as well as longitudinal furrows, speech difficluties, CONFUSION or may be a decline in sharpness
  • Particularly if they are symptomatic;c /o dizziness with rising very telling 3 types of dehydration- one easiest to recognize with labs- hypertonic ( water deficit) Na > 150, serum osmolality >300 Water and electrolyte deficiency= isotonic Hypotonic- loss of lytes greater than loss of waqter
  • Symptomatic interventions- after if has occurred Easier to address hydration ad nutrition than it is to correct malnutrition and dehydration: proactive is best
  • All older adults who consume fewer calories than needed to support metabolism should be assessed for possible unrecognized diseases or problems (e.g., anorexia related to pneumonia or digoxin toxicity). Assess for possibility of depression. Failure to eat is not normal behavior. Allow the older adult to eat smaller, more frequent meals. If the individual prefers small amounts of food, do not deliver regular-size portions; they may cause an aversion to food. Allow the older adult to consume finger foods. Persons with cognitive impairments may need cuing to eat. They may not recognize food or eating implements. They may be unable to express food preferences (this information should be obtained from a reliable informant). Short-term memory loss may cause persons to forget they have eaten, and they may request to eat over and over. To older adults with severe arthritis and other pain-producing illnesses, offer pain medication before meals. If another person is assisting the older adult with meals, the caregiver should sit next to or across from the individual, facing him or her. Never use a syringe to feed an older adult. If an older adult needs that much assistance with the stages of swallowing, most likely neuromuscular deficits are not allowing protection of the upper airway. Aspirations will eventually result. In institutional settings, schedule staff members’ meals at different times than patient meals. Do not make an older person feel that feeding him or her is a burden.
  • Food intake less than 50% at a meal – don’t wait, intervene; liberalize diet- better to eat something than little or nothing; nutrient dense foods NPO for multiple concurrent tests- rearrange to space them so pt can get food and fluids ; if npo for extended time be sure they have IV hydration Encourage fluid intake of 1500 ml- don’t wait until IV is out- may actually get it out sooner this way; unless medically contraindicated- chf, renal Involve pt- explain nl aging diminishes thirst “alert” and they need to consciously drink when not thirsty- studies show older pts will try when informed Company during meals- we all eat more when we have this; meals are a social event for most people; family , friends, bring favorite foods as allowed
  • If feeding a patient- when have memory issues- may try mime actions sit across as though at dinner table Cues and Gestures Hand over older person’s hand Pantomime gestures Sit across (Model eating behavior Use adaptive devices that work eyeglasses, hearing aids, dentures, sports bottles, straws/cups with lids (tremors) Silent aspiration Look for repeated swallows to move food, thick or congested voice or coughing while eating Do not provide nutritional supplements WITH meals- use between as with med passes; these are rich and may result in diarrhea so introduce slowly: start with ¼ to ½ can a day for several days then if no change in bowel habits increase to a full can and continue like this
  • As you go back to care for your patients, consider the points we made here today. It is critical to perform an assessment of the patient’s diet history and nutritional status. BMI is a good place to start, but more importantly, you need to look for age related changes, cognitive impairment, depression, effects of medications, and examine the serologic parameters to offer a more comprehensive plan to address nutritional issues. Use the Geriatric Oral Health Assessment Index, the Nutrition and Hydration Assessment Tools, and don’t forget the Yesavage Depression Scale. You can then plan the patient’s dining experience in a manner that meets their needs.
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  • Nutrition in Older Adults with voice overs

    1. 1. Nutrition and Hydration in the Older Adult
    2. 2. Objectives <ul><li>Discuss demographics related to nutritional issues in older adults. </li></ul><ul><li>Assess diet history and nutritional status, with special attention to cultural, ethnic, or religious preferences. </li></ul><ul><li>Evaluate anorexia in older adults. </li></ul><ul><li>Identify contextual factors that contribute to optimal dining experiences. </li></ul><ul><li>Plan care to maximize the self-feeding capacity of an older adult. </li></ul><ul><li>Plan mealtime care for an older adult with cognitive and/or physical impairments. </li></ul>
    3. 3. Definitions <ul><li>Malnutrition : any disorder of nutrition status </li></ul><ul><ul><li>including disorders resulting from inadequate intake (too little in) </li></ul></ul><ul><ul><li>over-nutrition (too much in) </li></ul></ul><ul><ul><li>improper metabolism </li></ul></ul><ul><li>Overweight older adults (75+ years) </li></ul><ul><ul><ul><li>Men=56.5% Women=52.3% </li></ul></ul></ul><ul><li>Obesity in older adults (75+ years) </li></ul><ul><ul><ul><li>Men=13.2% Women=19.2% </li></ul></ul></ul>
    4. 4. Demographics <ul><li>Frequency of Malnutrition in Older Adults: </li></ul><ul><ul><li>Independent Living: 1% TO 15% </li></ul></ul><ul><ul><li>Institutionalized: 25% TO 85% </li></ul></ul><ul><ul><li>Hospitalized: 35% TO 65% </li></ul></ul><ul><ul><ul><ul><li>Worsens during hospitalization </li></ul></ul></ul></ul>
    5. 5. Increased Risks <ul><li>Malnourished older adults are more likely to experience: </li></ul><ul><ul><li>Longer hospital stays </li></ul></ul><ul><ul><li>Increased hospital costs </li></ul></ul><ul><ul><li>Diminished muscle strength </li></ul></ul><ul><ul><li>Functional impairments </li></ul></ul>
    6. 6. Increased Risks <ul><ul><li>Nutrition affects CO, HR, BP </li></ul></ul><ul><ul><li>Medications bound to protein have higher levels </li></ul></ul><ul><ul><ul><li>Standard dose could be toxic (dilantin/coumadin) </li></ul></ul></ul><ul><ul><li>Immune system </li></ul></ul><ul><ul><ul><li>Poor wound healing and new pressure ulcers </li></ul></ul></ul><ul><ul><li>Infections </li></ul></ul><ul><ul><li>Post operative complications </li></ul></ul><ul><ul><ul><li>Higher risk for emboli </li></ul></ul></ul><ul><ul><ul><li>Edema/ascites and/or diarrhea if protein drops </li></ul></ul></ul><ul><ul><li>Death </li></ul></ul>
    7. 7. Factors Involved <ul><li>Progressive loss of lean body mass - decreased BMR </li></ul><ul><li>Disease, stress, injury, chronic drug use </li></ul><ul><li>Overeating and lack of exercise </li></ul><ul><li>Diminished sense of taste and smell </li></ul><ul><li>Loneliness </li></ul><ul><li>Physical and mental handicaps – immobility and chronic illness </li></ul>
    8. 8. Screening and Assessment <ul><li>Nutritional Screen needs to be completed within 24 hrs of admission </li></ul><ul><ul><li>current weight & weight history </li></ul></ul><ul><li>Three-day food diary (if memory intact) </li></ul><ul><li>Assessments should include </li></ul><ul><ul><li>Baseline- nutritional patterns, abilities </li></ul></ul><ul><ul><li>Lab results- albumin, prealbumin </li></ul></ul><ul><ul><li>Unintentional weight loss prior to admission – red flag if 10# in 6 months! </li></ul></ul>
    9. 9. Screening and Assessment <ul><li>Calorie counts </li></ul><ul><li>Less than 50% eaten </li></ul><ul><ul><li>document and intervene! </li></ul></ul><ul><li>NPO for more than a few hours </li></ul><ul><li>Inconsistencies between reported diet and what you see physically </li></ul><ul><ul><li>may indicate poverty, elder neglect/abuse </li></ul></ul><ul><ul><li>Fluid intake correlates to food intake </li></ul></ul>
    10. 10. Screening and Assessment <ul><li>Physical Assessment </li></ul><ul><ul><li>skin turgor, lesions, color, thick or brittle hair, muscle wasting, oral status (loose teeth; poorly fitting dentures), oral lesions, beefy red tongue </li></ul></ul><ul><li>Serologic parameters </li></ul><ul><ul><li>prealbumin & serum transferrin (early markers); serum albumin (late marker) </li></ul></ul>
    11. 11. Diet History and Nutritional Status <ul><li>Other serologic parameters </li></ul><ul><ul><li>total protein, BUN/Creatinine ratio, CBC, Blood glucose, iron stores, ferritin, B12, lipids </li></ul></ul><ul><li>Performance-based functional status </li></ul><ul><li>Inconsistencies between reported diet and biochemical / physical parameters </li></ul>
    12. 12. <ul><li> </li></ul>
    13. 13. Dehydration <ul><li>50% mortality if untreated </li></ul><ul><li>Often primary or secondary reason why the patient is in the hospital </li></ul><ul><li>Hydration status must be performed on all older people </li></ul><ul><ul><li>Normal aging causes decrease in total fluids </li></ul></ul><ul><ul><li>I/Os are very important! </li></ul></ul>
    14. 14. Dehydration <ul><li>Elderly may present differently than younger people, symptoms can be subtle: </li></ul><ul><ul><li>Irritability, confusion, lightheadedness, change in mental status, headache, loss of appetite, lethargy (very tired) or fatigue, low urine output or dark urine, constipation, fecal impaction, infection, muscle weakness </li></ul></ul>
    15. 15. Dehydration Assessment <ul><li>Poor skin turgor, dry mouth and lips, subtle change in baseline: families may report “Mom doesn’t seem herself today” </li></ul>
    16. 16. Dehydration <ul><li>Check Orthostatics </li></ul><ul><ul><li>A fall in blood pressure of 20mm Hg systolic (from lying to standing) </li></ul></ul><ul><ul><li>and/or a rise in pulse by 15 beats per minute often means a person is dehydrated </li></ul></ul><ul><li>Lab tests </li></ul><ul><ul><ul><ul><li>NA (hyper and hyponatremia) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>K+ (hyperkalemia) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>creatinine (not as reliable in elderly- Why?) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>BUN </li></ul></ul></ul></ul><ul><ul><ul><ul><li>urine specific gravity </li></ul></ul></ul></ul><ul><ul><ul><ul><li>urine electrolytes </li></ul></ul></ul></ul>
    17. 17. Dehydration <ul><li>Alleviate dry mouth: </li></ul><ul><ul><li>Avoid caffeine, dry, bulky, spicy, salty foods </li></ul></ul><ul><ul><li>Sugarless hard candy or chewing gum to stimulate saliva (not for patients with dementia or dysphagia) </li></ul></ul><ul><ul><li>Applying petroleum jelly to lips or dentures </li></ul></ul><ul><ul><li>Frequent small mouthfuls of water </li></ul></ul><ul><ul><li>Artificial saliva </li></ul></ul>
    18. 18. Cognitive and Physical Impairments <ul><li>Assess for possible unrecognized diseases or problems </li></ul><ul><li>Allow smaller, more frequent meals </li></ul><ul><li>Cue the person with cognitive impairments </li></ul><ul><li>Sit next to or across the person </li></ul><ul><li>Do not use a syringe to feed </li></ul><ul><li>Schedule staff </li></ul><ul><li>Burden-free attitude about feeding. </li></ul>
    19. 19. Be Proactive <ul><li>Improve oral intake: </li></ul><ul><ul><li>Mealtime checks </li></ul></ul><ul><ul><li>Encourage family members </li></ul></ul><ul><ul><li>Small, frequent intake </li></ul></ul><ul><ul><li>Pain meds </li></ul></ul><ul><ul><li>Pleasant environment </li></ul></ul><ul><ul><li>OOB </li></ul></ul>
    20. 20. Be Proactive <ul><li>Cues and Gestures </li></ul><ul><li>Use adaptive devices that work </li></ul><ul><li>Allow time – use finger foods </li></ul><ul><li>Difficulty in swallowing referred to SLP. </li></ul><ul><li>Dysphagia occurs in advancing dementia </li></ul><ul><ul><li>patient may eventually lose the ability to swallow and eat or drink. </li></ul></ul><ul><li>Supplements </li></ul>
    21. 21. What Do You Think? <ul><li>Which of these situations is an example of nosocomial malnutrition? </li></ul><ul><li>Decreased intake related to a disease process </li></ul><ul><li>Failure to replace meals held for tests </li></ul><ul><li>Anorexia related to an underlying eating disorder </li></ul>
    22. 22. What Do You Think? <ul><li>Malnutrition in a hospital usually refers to </li></ul><ul><li>Carbohydrate- fat intake </li></ul><ul><li>Protein-carbohydrate intake </li></ul><ul><li>Fat-protein intake </li></ul><ul><li>Protein-calorie intake </li></ul>
    23. 23. What Do You Think? <ul><li>A patient who fails to consume adequate calories and protein is at increased risk for which of these complications? </li></ul><ul><li>Thromboembolism </li></ul><ul><li>Heart failure </li></ul><ul><li>Hepatitis </li></ul>
    24. 24. What Do You Think? <ul><li>A patient who develops hypoalbuminemia related to protein deficiency should be monitored for toxicity to which of these meds? </li></ul><ul><li>Warfarin </li></ul><ul><li>Dilantin </li></ul><ul><li>Meperidine </li></ul><ul><li>Digoxin </li></ul>
    25. 25. What Do You Think? <ul><li>Which of these approaches would you use with a patient whose appetite deteriorates throughout the day? </li></ul><ul><li>Limit stimulation at meals </li></ul><ul><li>Encourage a big breakfast </li></ul><ul><li>Reduce physical activity </li></ul><ul><li>Offer double portions </li></ul>
    26. 26. <ul><li>Stechmiller, J. K. (2003). Early nutritional screening of older adults. Journal of Infusion Nursing, 26, (3) . 170-176. </li></ul><ul><li> </li></ul><ul><li>Guigoz, Y., Bruno, U., & Garry, P. J (1996). Assessing the nutritional status of the elderly: The Mini Nutritional Status as part of the geriatric evaluation. Nutrition Review. 54, S59-S65. </li></ul><ul><li> </li></ul>