Nutrition in the Elderly Population with Wounds

Hunter Somerville

March 16, 2010

Nutrition 302 Research Paper

Hunter Somerville

Nutrition in the Elderly

Spring 2010

Nutritional status in the elderly population can be diminished. Factors that can lead to a
decreased nutritional state are physical, psychological, socio-economical, and pharmacological.
Physical factors can be the inability to feed oneself, inability to prepare a meal, or immobility.
Psychological factors can be loneliness, depression, dementia, or Alzheimers. Lower
socioeconomic status can limit the patients ability to purchase nutritious foods and limit trips
to the doctor or dentist. Pharmacological side effects of medications can decrease appetite,
increase urine output, or decrease absorption of nutrients in the digestive tract. Other factors
that can play a role in malnutrition are decreased tastes, absence of teeth or poor fitting
dentures, and the presence of chronic illnesses such as diabetes, heart disease, kidney disease,
or COPD (Chronic Obstructive Pulmonary Disease (1,2). Stress from any of these physical,
social, or psychological issues has a detrimental effect on nutritional status (1). Malnutrition
can lead to unintentional loss of weight and loss of Lean Body Mass (LBM). As nutritional status
continues to fall, there is an increased risk for wounds to appear and any existing wounds will
be slow to heal (3,5). To improve nutritional status and promote healing requires prompt
assessment of the individual elderly patient. Then their nutritional needs must be determined
and a plan of action instituted with interventions to maintain the proper level of nutrition (4,6).
First we must examine the additional causes to the underlying condition of malnutrition.
There can be underlying physiologic concerns that must be addressed, some of which could be
gastrointestinal malabsorption or other gastrointestinal losses due to diarrhea. Another
consideration is that a patient may not eat due to a fear of choking because they suffer from
dysphagia. Dysphagia is the inability of a person to swallow properly and fluid or foods may go
into the lungs or cause choking (1,7). If the person is in a hospital or a nursing home the food
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they are receiving may not be of a high enough concentration to prevent malnutrition. Also
time between meals can be of a concern especially if the patient doesnt get an evening snack.
This long time period between and evening meal and the next morning can lead to a decreased
nutritional state (1,7,9).
When a patient is suffering from malnutrition this can lead to the loss of the bodys fat
stores. Once fat stores are gone the body begins to break down protein for energy and this
causes a loss of Lean Body Mass. Loss of LBM can be contributed to an infection or an injury.
Injury could be an accidental fall or deliberate such as a surgical incision. This infection or injury
triggers the bodys stress response mechanism that initiates a hypermetabolic and catabolic
state. Catabolism is the bodys break down of tissues, especially muscle mass, for energy. A
hypermetabolic state is one of increased energy needs by the entire body. As the catabolism
continues, loss of LBM increases. This ultimately leads to Protein-Energy Malnutrition (PEM)
(3,6). PEM happens when the energy and protein needs of the individual exceed the intake.
Protein-energy malnutrition (PEM) is the most common form of malnutrition in people with
wounds (6). Loss of LBM and the combined PEM leads to the involuntary weight loss and this
in turn has a negative impact on the healing of wounds (8). An additional factor that can lead
to involuntary weight loss and PEM is short stays in an acute care setting and then rapid
transfer to home, a rehabilitation clinic, or a long term care facility. This rapid transition can
prevent the diagnosis and correction of malnutrition. This prevents the restoration of the LBM
and necessary protein reserves to reverse the PEM (6). The stress of the transfer from one
facility to the next can actually elevate the bodys hypermetabolic and catabolic state increasing
loss of lean body mass (1).
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Hunter Somerville

Nutrition in the Elderly

Spring 2010

Understanding involuntary weight loss and how it is defined is essential to correcting

the problem and healing the patient. One of the most common markers for PEM is
unintentional weight loss. Defined as 5% loss of body weight in 30 days, 7% loss in 3 months,
or 10% loss in 6 months, this amount of weight loss may produce a significant health risk (6).
This definition is not derived from a persons ideal weight but the weight at the beginning of
the loss whether it is a normal weight, underweight, or overweight status. Involuntary weight
loss can lead to the loss of LBM and PEM. There are four stages of complications and
mortalities associated with the loss of Lean Body Mass. The first stage is loss of LBM up to 10%
of the total Lean Body Mass. In this stage the patient has increased risk for infections and
lowered immunity. The mortality for stage one is approximately 10%. The second stage is a
loss of LBM up to 20% of the total. In the second stage a patient has decreased healing and
signs of weakness. The mortality rate in stage two is approximately 30%. The third stage is loss
of LBM up to 30% of the total. At this stage the patient has no healing, the patient may be too
weak to sit, and there is great risk of developing pneumonia. The mortality rate in stage three
is approximately 50%. The fourth stage is a loss of LBM up to 40% of the total. At this stage
because of a weakened immune system the patient develops pneumonia and dies. The
mortality rate at this stage is 100% (6,7,8).
A patient that has suffered involuntary weight loss, loss of Lean Body Mass, and entered
into a state of Protein-Energy Malnutrition will continue to lose until the process is reversed.
During this state wounds can spontaneously appear due to diminished skin integrity. If the loss
is greater than 10% the wounds will be slow to heal because the body is trying to replace lost
protein stores before initiating healing. The types of wounds present correlate to the amount
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Hunter Somerville

Nutrition in the Elderly

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of involuntary weight loss. The greater the loss the more severe the wounds may be or there
may be increased numbers of wounds. The appearance of spontaneous wounds can further
escalate the bodys hypermetabolic and catabolic states (4,8). The degree of hypermetabolism
and catabolism is dependent on both the degree of injury and the host response to injury (8).
The increased demands require increased nutritional support to overcome the malnutrition
(1,8).
The impaired healing process of wounds in the elderly requires adequate assessment of
the individual persons needs. Wound healing processes include meeting proper nutritional
needs, reversal of loss of Lean Body Mass, reversal of Protein-Energy Malnutrition, and proper
wound care including infection control practices (2,6). To determine these needs a physical
assessment of the individual must be performed. Evaluation of the physical state including
weight loss, muscle loss, and current blood test of nutritional evaluators should be performed.
Consideration should also be given to other existing chronic conditions. Once an assessment
has been made, a plan for correcting the impaired healing and the malnutrition should be
made. Factors to include in this plan are how to control and reverse the catabolism, reverse
the malnutrition, how to increase adequate nutrient intake to meet energy demands of the
healing body, and the requirements of increasing protein intake to reverse PEM (2,4). Once an
assessment and plan have been constructed, treatment can begin to start the healing process
(2,8).
To begin the assessment process the practitioner must assess each patient on an
individual basis. The persons height must be accurately measured and recorded. Then the

Hunter Somerville

Nutrition in the Elderly

Spring 2010

persons weight must be obtained, recorded, then compared to previous weights to determine
the amount of weight loss and the percentage loss of LBM (5,6). At this point it is a good idea
to note any other factors that can be indicators of malnutrition. These would be signs such as
dull hair, irregularities in finger nails or nail beds, mouth dryness or sores, if the membranes
around the eyes are pale or have yellowish bumps present, or any other noticeable changes in
normal body features (2,10). The height and weight are then calculated to determine BMI,
Body Mass Index, of the patient. A BMI of below 18.5 is underweight, between 18.5 and 25.0
is an indication of healthy weight, 25.0 to 30.0 is overweight, more than 30.0 is referred to as
obese, and more than 40.0 is morbid obesity (2). A laboratory test that can help assess
malnutrition is serum albumin level. Decreased albumin in blood tests is an indicator of
malnutrition. When using serum albumin level as an indicator, special note must be made of
other underlying diseases that can affect this level. They are liver disease, nephrotic
syndromes, dehydration, or cancers. Once physical assessment is complete, nutritional status
must be evaluated (2,3,6).
Nutritional status assessment must encompass several factors including the patients
socioeconomic status, social network, and food intake history. A patient with a lower
socioeconomic status is at higher risk to be malnourished or have trouble recovering from
malnutrition because they cant afford the proper diet or additional medical care (1,2). The
absence of a social network to help with feeding, cooking, and monitoring of intakes can
exacerbate the malnourished state. This lack of social interaction creates loneliness and
depression that can lead to a decrease in appetite and increase in stress levels (1,7). Now that
all the factors have been accounted for a plan for nutritional supplementation can be started.
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Hunter Somerville

Nutrition in the Elderly

Spring 2010

The practitioner must calculate the energy requirements or calorie intake necessary to provide
adequate nutritional support and to help reverse the consumption of calories from the
hypermetabolic state. Second, the practitioner must make calculations of protein requirements
to reverse PEM and to restore Lean Body Mass. Then there must be complete evaluation of the
micronutrient supplementation needs. With all factors and calculations made, a plan of
nutritional support can be made (2,6).
Calculation of the energy requirements to determine adequate calories is obtained by
measuring daily expenditures and then adding in increases to correct the malnutrition. First the
Basal Metabolic Rate (BMR) must be determined. The BMR is determined by calculated
expenditures of the body at complete rest after fasting for 12 to 18 hours. Then the BMR must
be adjusted for the stress factor associated with the disease, trauma, or wound (4,6). Stress
factor multipliers are Minor injury 1.2, Minor surgery 1.2, Clean wound 1.2, and Infected
wound 1.5 (4). The next step is determining the patients activity level and applying the
correct factor of 1.0 for patients confined to a bed, 1.2 for patients that are ambulatory, and 1.5
for patients that are very active (6). Then to calculate energy expenditure you multiply BMR by
stress factor and then by the activity level. The average elderly patient with normal activity
requires approximately 20 kcal/kg/day. The malnourished person with a wound requires at
least a 50% increase in calories to 30 kcal/kg/day (4,6).
Macronutrients of importance and especially important in the healing malnourished
patient are proteins, carbohydrates, and fats. Protein requirements must be calculated to
restore the bodys Lean Body Mass and correct the Protein-Energy Malnutrition. The amount

Hunter Somerville

Nutrition in the Elderly

Spring 2010

of protein required by a normal healthy elderly adult is about 0.8g/kg/day. Protein at this level
of intake keeps the body in homeostasis of protein synthesis and protein breakdown. A person
suffering from malnutrition requires almost double the normal amount of protein. The amount
recommended for a patient with malnutrition is 1.5g/kg/day (4,7). Carbohydrates should
contribute about 55 - 60% of the daily intake of calories. Carbohydrates should be provided in
the form of complex carbohydrates. Simple sugars should be minimized because they can
increase blood glucose level and lead to hyperglycemia. Carbohydrates support many cellular
functions involved in the healing process. Fats provide additional calories in the diet and are
essential in cellular functions, cell membranes, and are precursors to prostaglandins. Fats
should not exceed 20 25% of the daily intake of calories (7,10). Water intake should be
monitored to prevent dehydration. Water intake should be approximately 25 to 30 mL/kg/day
at a minimum of 1500 mL per day. PEM lowers thirst reducing the fluid intake of the patient
and leading to dehydration (3,6).
Micronutrients also play a vital role in the patient that is suffering from malnutrition.
The key micronutrients are vitamin A, vitamin C, B vitamins, iron, zinc, and manganese. In a
malnourished patient the Recommended Daily Allowances may not be adequate. Use of a
daily high potency multivitamin and mineral supplement is recommended for all patients with
poor skin integrity who may be suspected of having vitamin or mineral deficiencies (2).
Vitamin A helps in the wound healing process by aiding in debridement of wounds and helps in
cell mediated immunity. Vitamin C helps the bodys immune response and assists in
phagocytosis of debris in wounds. B vitamins thiamine, riboflavin, B, and folic acid assist in the
formation of leukocytes. B vitamins also increase metabolic activity that helps in wound
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Nutrition in the Elderly

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healing. B vitamins additionally stimulate anabolic processes that counteract catabolic activity
in the body (4,7,10). Iron is an essential mineral because it helps to increase oxygen transport.
Increased levels of oxygen promote wound healing. Zinc is a component in cellular replication,
RNA and DNA synthesis. Zinc stimulates the activity of more than 100 enzymes and is
necessary for membrane stability and the maturation of collagen in the proliferative and
remodeling phases of wound healing (7). Manganese is responsible for helping in collagen
synthesis which aids in wound healing and strengthens the integrity of skin (6,7).
When implementing the patients nutritional plan the type of supplementation that will
be administered should be considered. Whole foods can be planned if the patient can chew
and swallow properly. The preferred means of nutritional support is through the enteral route.
For the patient, this preferred route is also less expensive and safer because it protects the
mucosal barrier of the esophagus and stomach. Parenteral tube feedings may be necessary for
the patient if they cannot sit to eat or have difficulty swallowing. Parenteral tube placement
through the outer wall of the stomach also increases the risk of infection. If liquid
supplementation is instituted, there are several formulas that are available including ones for
protein replacement and wound care (2,3).
Hormone therapy may be used in certain patients to help promote anabolic processes
and create replacement of LBM. These hormones can stop and reverse catabolism in the body.
Human Growth Hormone promotes the production of insulin-like growth factor-1; this
hormone can promote wound healing. Some side effects of HGH are hypermetabolism and
there is increased mortality in certain critical care populations. HGH is approved by the FDA for

Hunter Somerville

Nutrition in the Elderly

Spring 2010

use only in short-stature children, therefore, it has to be used off label in adults. Oxandrolone
is another hormone and it is approved by the FDA for use in trauma patients. Oxandrolone is
removed by the kidneys and poses no risk to the liver. The primary complication from the use
of Oxandrolone is carcinoma of the male breast and prostate (6,9).
The nutritional status in the elderly population may diminish to a state of malnutrition
leading to the spontaneous appearance of wounds or pressure ulcers. This can happen to a
person at home, in the hospital, or in a long term care facility. Many factors can lead to
malnutrition such as the existence of chronic illnesses, aging and frailty, psychological issues
such as depression, low socioeconomic status, or lack of a social network. Severe malnutrition
can lead to a loss of Lean Body Mass and a state of Protein-Energy Malnutrition. Wounds can
spontaneously appear and any existing wounds may be slow to heal. Proper intervention and
assessment are essential to stopping and reversing the involuntary weight loss suffered by the
patient. A nutritional plan that supports the patients individual needs is essential to the
recovery and healing process. Determining the proper amounts of macronutrients,
micronutrients, and water intake are vital parts of stopping PEM and restoring LBM. Once this
happens, wound healing takes place. Minimizing the patients stress level will help reduce the
catabolism and restore normal functioning to the body. With proper intervention, the number
of patients suffering from malnutrition can be lowered and the potential for spontaneous
wounds reduced.

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Hunter Somerville

Nutrition in the Elderly

Spring 2010

References:
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