Undernutrition in the old age-costs and treatment implications
Danit R Shahar, RD, PhD
Danit R Shahar, RD, PhDThe S. Daniel Abraham International Center
for health and NutritionBen-Gurion University-Israel
Clinical dietitian PhD in nutrition epidemiology PhD Thesis: Factors associated with dietary
intake and eating habits of community dwelling elderly people living in Pittsburgh, USA
Areas of interest: Dietary assessment methods Factors associated with undernutrition among
the elderly
Personal Statement
My professional commitment is to study and develop research programs and teach students of all health disciplines the topic of geriatric nutrition.
The work may create these people as leaders in their communities and thus change people views and attitudes toward older people.
Learning objectives:
To understand the concept of undernutrition among the elderly population
To understand the implications of undernutrition in terms of health consequences, cost and treatment
To be familiar with the main risk factors and causes for nutritional deterioration and deficiencies
To understand the basic concepts of dietary assessment of the elderly population
Nutritional status of the elderly population-the prevalence of undernutrition
COMMUNITY SURVEYS: 35-40% < 2/3 RDA calories (Bidlack 1992) 70--78%< RNI* calories (Payette, 1995)
48-60% < RNI* Protein (Payette, 1995)
NURSING HOME SURVEYS:
5-18% < RDA calories (Rudman, 1989) 0-33% < RDA protein (Rudman, 1989)
*RDA=Recommended Dietary Allowances**RNI=Recommended Nutrient Intake-Canadian recommendations-Different approach than the RDA
Nutrient NHANES I NHANES II NHANES III (1971-74) (1976-80) (1988-91)
Calories 16%-18% 20%-30% 25%-40%Riboflavin 6%-36% 7%-13% 15%-20%Vitamin B6 50%-90% 54%-69% 25%-50%Vitamin A 42%-65% 22%-36% 25%-30%Vitamin C 23%-58% 22%-31% 15%-25%Calcium 40%-50% 30%-43% 25%-50%
Table I:Percentage of inadequate intake of nutrients based on NHANES I II and III data
(The NHANES III data is based on NCHS/CDC)
0
20
40
60
80
100
120
Percent of the DRI
Selected nutrientsMenWomen
Dietary intake as compared with the DRI: (Negev Nutrition Study):
Do we treat undernutrition?
McWhirter & Pennington BMJ, 1994 -Only 2% of undernourished hospitalized patients are being treated. 5% were referred to treatment during their hospitalization..
During hospitalization 64% of the patients have lost weight.
70% showed improvement in their nutritional status after treatment.
General consequesnces of undernutrition:
Weight loss is associated with a decline in function ability (Allison, 1992)
Delayed wound healing (Hill, 1992) Impairment of the immune system which may
increase the risk and consequences of infection (Chandra, 1988)
With severe weight loss, both cardiovascular and gastrointestinal functions are impaired
Malnourished people may become depressed and apathetic (Brozek, 1990)
General consequesnces of undernutrition II:
Loss of muscle strength (Lesourd BM, 1995)Increase in fractures Increased incidence of pressure sores Specific micronutrient deficiencies
Malnutrition and post-surgical complications (Meguid, 88)
29
72
4
23
0
10
20
30
40
50
60
70
80
Complication rate Post-operativemortality
Well nourishedMalnourished
P<0.001
P<0.001
Cost of a stay in hospital in malnourished and well nourished patients with or
without major complications (Reilly, 88)
Cost of average hospital stay
Malnourished pt. with major complications (n=67)
$12,683
Normally nourished pt. With major complications (n=20)
$7,375
Malnourished pt. With no complications (n=312)
$3,469
Normally nourished pt. With no complications (n=304)
$2,968
Energy balance:Naturally there is a decrease in energy needs.Till 70 years old there is a positive energy
balance associated with weight gain After age 70 we can see a negative balance
associated with weight loss. Lean body mass and body fat tend to be reduced (Morley)
Weight loss in the older age is associated with increased mortality and morbidity
Weight, weight change, and mortality in a random sample of older community-dwelling women -JAGS 47: 1409-1414
0
5
10
15
20
25
30
%
Loss No Change Gain Cycle
Weight change categories
LowAverageHighTotal
White older community-dwellers women are at increased risk of mortality
if they are underweight, lose weight or weight cycle
RR for mortality according to BMI among older people 70 years and older:
AJCN 2001 55(6):482-492
0,6
0,8
1
1,2
1,4
1,6
1,8
RR Males
Females
Risk facrots for undernutrition
Physiological factors:– Impaired senses of
smell/taste– Dental problems– Decreased gastric acid
secretion– Medication/Medical
problems– Decreased mobility
affecting purchase and preparation of foods
Drug therapy in the old age -Nutritional aspects
Multiple medication due to co-morbidities Effect of medications on digestion and absorption Direct effect of medications on appetite Medication may decrease or distort taste and smell Certain medication may cause oral dryness Certain medication may decrease mobility of the
stomach and gastrointestinal tract Diarrhea and decreased absorption (antibiotics) Behavioral aspects Changes of nutritional needs (diuretics)
Medication and appetite:
Increase appetite and food intake
Steroids Sex hormones Antipsychotic Antihistamin Prokinetic Kanavis
Decrease appetite and food intake
Sympathomimetics Anti-parkinsonian [L-dopa,
Sinemet] Antidepressants, SSRI,
Prozac and realted Rx Xantines [Theophylline] Digitalis
RISK FACTORS FOR MALNUTRITION: (cont)
Socioeconomic factors:– Declining income and retirement– Smaller household size– Loss of spouse– Isolation and institutionalization
Psychological factors: Depression Stressful life events mental confusion
Caloric intake by risk factors and gender
0200400600800
100012001400160018002000
Known risk factors for decreased dietary intake
Me
an
ca
lori
c i
nta
ke
men-yes
men-no
women-yes
women-no
** ** **
Eating habits and caloric intake – NNS results:Decreased appetite, low snacking, gastrointestinal problems
and poor health status were associated with low caloric intake
*
Click for larger picture
Other risk factors for undernutrition among the elderly population:
Eating less than needed-fewer products and smaller meals or portions
Decreased appetite and early satiety Changes in energy regulation Changes in the levels and function of
neuropeptides (NO decrease, CCK increase>>>early satiation)
Decreased enjoyment of eating
What patients are at risk for nutritional deterioration? Cancer
Cardiovascular Heart Failure Chronic Obstructive Pulmonary Disease (COPD) Post-surgery Gastrointestinal diseases Liver Cirrhosis Renal Failure Depression DementiaThese diseases may be hypermetabolic and / or induce
anorexia
What are the most typical nutritional deficiencies in the old? Vitamin B12 (Usually not dietary) Folic acid Vitamin B6 Antioxidants vitamins Zinc Vitamin D Calcium Vitamin K
Factors associated with nutritional deficiencies
Eating lower nutritional quality foods such as bread and butter exclusively
General and specific deficiencies due to higher needs, co-morbidity and multiple medications.
Physiological and pathophysiological changes in the gastrointestinal system impact the ingestion and digestion of nutrients
Unnecessarily restrictive diets
PhysiologicalSocioeconomicPsychological
Ris
k fa
cto
rs:
Loss of motivation/will to eat
General deterioration“I am not important to anyone”
Nutritional deficiencies
Eat small amounts
Intervention strategies:
Treatment of risk factors
Regaining physical and emotional strength
Quality of life improve
Better eating
Weight as a key measurement for nutritional status
Weight history is one of the simplest and most consistent measure (Mobarahan 1991)
Weight change is a key variable in nutrition assessment in the elderly (Jeejeebhoy 1991)
Recent weight loss is a sensitive indication of individuals at nutritional risk (Fogt 1995)
Weight loss as an indication of nutritional deterioration
An involuntary weight loss of 10% of more especially over a short period of time
weight loss of 1 kg per week, 2 per month.Weight loss trend over time
Nutritional assessment:
Assessment of appetiteAre all food groups included in each meal
(5 colors of food per meal)Enjoyment of eatingUse of Mini Nutritional Assessment
(MNA) or eating behavior questionnairesBiochemical and clinical assessment
Recommendations: Dietary assessment as part of geriatric assessment Healthy eating Encourage Snacking High quality drinks or supplements (shakes) Caution with prescribed “medical” diets Judicious use of medication Treating risk factors (depression) Fortified foods Supplements [energy!!! + nutrients] Encourage weight stability, avoid loss!!!