Nutrition Aspects in Elderly

Pranithi HongsprabhasDivision of Clinical Nutrition, Department of Medicine,

Faculty of Medicine, KKU

Outline

Nutritional disorders Over nutrition Under nutrition

Etiology of malnutrition Nutrition related problems

Introduction

Changes in aging nutritional risk

Organ system reserve Weaken homeostasis control heterogenicity of response

Genetic Environment

Geriatric failure to thrive (FTT)

FTT: state of decline Decline in vitality… The causes of deterioration: not

identifiable or irreversible..

Undergo a process of functional decline, progressive apathy and loss of willingness

to eat and drink that culminate in death

4 Syndromes of FTT

Impaired physical function Malnutrition Depression Cognitive impairment

Manifestation Weight loss > 5% of baseline Appetite Poor nutrition Inactivity Accompanied by

Dehydration Depressive symptoms Impaired immune function Low cholesterol

Undernutrition syndrome in elderly More common

home 2-32% Long term care 25-60% Institution 1-83% Hospital 30-65%

Greater impact: less able to adapt to underfeeding Less frequent hunger Not regain total # of weight

Consequences

Functional disabilities Nosocomial infection Perioperative complication Morbidity, mortality Longer LOS Increased health care expenditure

Etiology of under nutrition

Inadequate intake (starvation)

Altered absorption Nutrient loss

Nutrient metabolism

Weight loss in elderly

Inadequate intake Inflammatroy effect of illness

(cachexia) Muscle atrophy (sarcopenia of elderly)

Nutrient intake in elderly

Anorexia Physical illness: organ dysfuction, cancer,

infection Mental illness Medication

Poor oral/dental health Dysphagia Visual impairment

Influence of dental status on dietary intake

21.6 22.7

35

28.632.8

47.9

0

5

10

15

20

25

30

35

40

45

50

Poor appetite Dyspepsia

Adequate dentition

Use of dentures

inadequate dental status

P<0.01 P<0.001

%

0

20

40

60

80

100

120

Calories Protein Iron Folic B6 Vit C

Adequate dentition

Use of dentures

Inadequate dental status

Mea

n pe

rcen

tage

of

nutr

ient

inta

kes

GI problems in elderly and their relations to Nutritional disorders Dysphagia

Oropharygeal Esophageal

Atrophic gastritis Delayed GET Dyspepsia Diverticulum Colonic cancer

Atrophic gastritis Type A: pernicious

anemia (autoimmune)

Type B Chronic inflammation Associated with HP

Secretion of Acid Pepsin Intrinsic factor

0

5

10

15

20

25

30

35

40

60-69 70-79 80+

% Atrophic gastritis

Krasinski SD J Am Geriatr Soc. 1986 Nov;34(11):800-6.

Nutritional consequence of atrophic gastritis

availability and absorption of B12

(food-cobalamin malabsorption)

Ca absorption

non heme Fe absorption

0

50

100

150

200

250

300

350

400

450

500

Young adult Normal elderly elderly withatrophic gastritis

Serum B12 (pg/ dl)

Krasinski SD J Am Geriatr Soc. 1986 Nov; 34(11):800-6.

B12 deficiency

Megaloblastic anemia Neurological damage

SCDS Dementia

Atherosclerosis (hyperhomocysteinemia)

Nutrition metabolism related to body composition changes Body composition

Fat free mass Fat mass

Energy expenditure Decreased: with aging and lean body mass Increased:

Parkinsonism Cancer Infection Chronic cardiac failure Chronic pulmonary diseases

Nutrition metabolism related to body composition changes Protein requirement: increased

catabolism in diseases synthesis

Cachexia Cancer Cardiac Pulmonary Chronic infection energy requirment ~10-15 % protein requirement Hormonal control: cortisol,

catecholamine Cytokines: TNF, IL-1, IL-6

Sarcopenia: ~poverty of flesh

lean body mass Concomitant fat

mass

Multifactorial disorders

sex hormone: testosterone/DHEA GH and IGF-1 cytokine production Neuromuscular changes Physical inactivity Malnutrition

G H secretion

f at m ass

I nactiv ity

D isabilityM orbidityM ortality

S arcopenia E strogen/A ndrogen

W eakness m etabolicreserve

M uscle m ass

M uscle quality

P roinfl am m atorycytok ines

C N S input ( loss of m otor neurones,changed m otor unit activation)

Consequence of Sarcopenia

energy expenditure insulin sensitivity muscle strength risk of disability risk of fall risk of mortality

Distinguishing sarcopenia from cachexia

Sarcopenia Cachexia

Appetite Not affected Suppress in earlyFood intake Not affected BW May FFM Alb N Cholesterol May Cortisol May Inflammatory disease

Not present Present

Response to refeeding

Resistant Resistant

Pathway Not lead to cachexia

May lead to sarcopenia

Clin Nutr 2006;26:389-99

Exercise Training and Nutritional Supplementation for Physical Frailty in Very Elderly People

Mean Changes in Muscle Strength after

Fiatarone MA et al. NEJM 1994; 330:1769-1775

Mean (±SE) Changes in Energy Intake in the Four Study Groups

Nutritional screening

Mininutritional assessment (MNA)Screening Food intake (3mo) Wt change (3mo) Mobility Psychological or acute disease Neuropsychological preoblems BMI

Markers Screening tools

MNA Hx

Wt loss Dietary Hx Medical Hx

Anthropometry Lab

CBC Alb Chol

Nutritional Rx:

Rx causes of poor intake Nutritinal intake

Diet Oral nutritional supplement (ONS) Enteral tube feeding (ETF)

Possible strategies to improve oral intakeRisk Interventional strategiesLoss of appetite Check drug

Personally chosen food, Fortified menuappetizer

Chewing problems Dental care, oral hygiene, mushy food

Swallowing problems

Speech Rx, ETF

Difficulties preparing food

PT, nursing assistance

Chronic pain Analgesia Depression Check medication, medical Rx

Social isolation Social service, meals on wheels

Enteral nutrition Oral nutritional supplement

1081

957

45.9 38.3

0

200

400

600

800

1000

1200

Energy intake (kcal) Protein intake(g)

ONSControl

Bourdel-Marchasson I, et al Nutrition. 2000 Jan;16(1):1-5.

536 173 899. ( . to . )

Potter J, et al ใ BMJ199831;-7495501;

Meta-analysis of protein energy supplement (ONS)

ETF

Bourdel-Marchasson I, et al Nutrition. 2000 Jan;16(1):1-5 4.04 (3.15 4.94)to

Meta-analysis of protein energy supplement (ETF)

Potter J, et al ใ BMJ199831;-7495501;

Obesity in elderly

Diseases associated with obesity Cardiovascular, stroke HTN DM/Metabolic syndrome Dyslipidemia Cancer

Breast Endometrial Colorectal

GERD Cholelithiasis NASH OSA/OHS Asthma OA Gout Infertility PCOS incontinence

Am

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06;1

63:9

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Association of BMI and Wt Change with All-Cause Mortality in the Elderly

Degree of obesity and mortality in elderly

NEJM 1999;341:427-34.

Relation between in Wt and RR of Type 2 DM, HTN, CHD, and Cholelithiasis.

FU 10 yr, age 40-65 yr FU 18 yr, age 30-55 yr

NEJM 1999;341:427-34.

Voluntary Wt Reduction in Older Men Hip Bone Loss: The Osteoporotic Fractures in Men Study

Andres, R. et. al. Ann Intern Med 1993;119:737-743

Association of Mild to Moderate Weight Loss with All-Cause Mortality*

Treatment strategies

Preventing weight gain and overweight healthy weights and

avoiding further weight gain among those already overweight

are important public health goals. Weight reduction in pts with mobility

problem Therapeutic lifestyle control