NUTRITIONAL ASSESSMENT IN OLDER PERSONS

Medical Faculty Brawijaya University Malang 2011

Definition of Aging
Miller (1994)

Aging is a process which converts a healthy adult into a frail one accompanied with decrease in physiological capacity of the body system, and exponentially increase in vulnerability to disease and death. Aging is associated with gradual decline in performance of organ systems, resulting in the loss of reserve capacity, leading to an increased chance of death.

Percentage of People 60 years and over in selected Developing Country

Life Expectancy at Birth by World Region

90 80 70

60
50 40 30 1950-55 1970-75
Asia

1990-95
Northern America

2010-15
Europe

2030-35

Latin America and Caribbean

Africa

Total Fertility Rates by World region

Total Fertility Rate

1950-55

1970-75
Asia

1990-95
Northern America

2010-15
Europe Africa

2030-35

Latin America and Caribbean

OLD AGE

Fat mass Muscle mass Sarcopenia

Immunity Cognitive function Immobilization Gastrointestinal tract impairment

Chronic diseases Polypharmacy Isolation / depression Education Income

Food intake Body composition Lean body mass Fat mass Total body water

NUTRITIONAL STATUS

Malnutrition in the Elderly:

More common than you would think
2 - 10% free-living elderly populations 1 30 - 60% institutionalized elderly 1 40 - 85% nursing home residents 2 20 - 60 % home care patients 2
(1) Vellas, B. et al, NNWS, 1999, Volume 1; (2) Nutr Screening Initiative

Why the concern?

Malnourished elderly are:
2 times more likely to visit the doctor 3 times more likely to be hospitalized

Infection is the most common disorder

2 - 10 times more likely to die if malnourished

Diminished muscle strength Poor healing Malnutrition is a greater threat than obesity

Aging & Malnutrition

Why is this an issue?
Changes with aging:
Physical diminishing eye sight poor dentition taste changes poor swallowing

Physiological Metabolic Psychosocial changes

Aging and Energy Needs

With age, metabolism decreases
Body composition changes :
Muscle mass decreases as adipose tissue increases Results in 2% deceased metabolic rate per decade (Elmadfa and Meyer 2008)

Decreased physical activity less energy expenditure

Nutrient Consumption
30% of elderly consume less kilocalories than recommended (Lengyel et al 2008) Decreased intake due to
Loss of appetite depression, dementia Medication-induced anorexia (American Dietetic Association 2005) Impaired taste perception Decreased density of taste buds (Winkler et al 1999) Higher thresholds for detection of tastes (Fukunaga et al 2005) Loss of dentition Socioeconomic factors or functional disability effecting shopping and meal preparation (American Dietetic Association 2005)

Incidence of Malnutrition
Malnutrition is closely related to increased mortality and morbidity :
Greater susceptibility to infection and longer hospital stays (EscottStump 2008), increased risk of medical and surgical complications (Baker and Wellman 2005), increased risk of pressure ulcers, hip fractures, edema, cognitive changes (Escott-Stump 2008)

Incidence of malnutrition estimates range from 2078% (Bouillanne et al 2005) Guigoz et al 2002 :
2-10% of those living independently 30-60% of those hospitalized or institutionalized

Food Guide Pyramid

Aging and Micronutrient Needs

Vitamin and mineral needs remain unchanged with age Decreased food intake often results in deficient intakes of micronutrients
50% of older persons have lower than recommended intakes of micronutrients (Escott-Stump, 2008) 80% of elderly persons have inadequate intakes of at least on nutrient (Guigoz et al 2004)

Digestion, absorption, and synthesis of micronutrients are decreased (Elmadfa and Meyer, 2008)

Micronutrients of Concern
VITAMINS B6, B12, folate Vitamin E Vitamin C Vitamin D Vitamin A Thiamine MINERALS Selenium Zinc Calcium Iron

B6, B12 and Folate

Atrophic gastritis seen in ~ 30% of patients (Elmadfa
et al 2008)

Reduced intrinsic factor production; reduced B12 absorption Clarke et al 2003 found
10-20% of subjects were at high risk for B12 and folate deficiencies based on blood levels, serum homocysteine and methylmalonic acid. 10% of subjects who were B12 deficient were also folate deficient.

Buell et al 2007 found

39% subjects deficient in folate, 18% subjects deficient in B6

Deficiency Risks
High homocysteine levels resulting from B6, B12, folate deficiencies linked to increased cardiovascular disease risk and decreased mental agility (Marengoni
et al 2004)

Folate deficiencies linked to increased dementia and depression (DAnci et al 2004) Excessive folate intake can mask B12 deficiency
Corrects hematological signs of deficiency but not neurological signs. Neurological signs include fatigue, malaise, vertigo, cognitive impairment (Clarke et al 2003).

Thiamine and other water-soluble vitamins

Diuretics increases water-soluble vitamins losses as urinary excretion is increased Thiamine is especially at risk of becoming deficient due to diuretics Low dose thiamine supplement in the elderly on diuretics may be useful in preventing deficiency
(Escott-Stump 2008)

Vitamins A, E, and C
Commonly deficient Lengyel et al 2008 found 10%, 84%, 49% of subjects deficient respectively Frail elderly are more likely to be deficient vitamin E and A (Michelon et al 2006) Centenarians are more likely to have high levels of Vitamin E and A (American Dietetic Association 2005) Needed for drug metabolism and detoxification

Antioxidants
Vitamin C, E, beta-carotene needed in adequate supply for decreasing oxidative damage to tissues and cells including immune cells (Elmadfa and Meyer
2008)

Balanced diet seems to be more effective than supplementation for improved immune function (Chandra 2004) but supplementation may be effective (DAnci et al 2004)

Calcium and Vitamin D

Bone mass decreases with age especially in women resulting in osteoporosis Direct health care cost of $12-18 billion each year just for fractures (USDHHS 2004) Absorption of calcium and vitamin D effected by age receptor expression in duodenum decreases (Elmadfa and
Meyer 2008)

Vitamin D synthesis decreases (MacLaughlin et al 1985) Less time spent exposed to sunlight (Escott-Stump 2008) Vitamins A and K, and magnesium effect bone health as well, but more research needed (American Dietetic
Association 2005)

Selenium, Zinc, Iron

Depression in the elderly is associated with low levels of selenium (Gosney et al 2008) Low levels of selenium, zinc, and iron linked to reduced cell-mediated immune response (Wintergerst
et al 2007)

Low zinc intake associated with increased wounds and severity (Tobon et al 2008)

Nutrition Screening
Purpose : to quickly identify individuals nutritionally at-risk or who are malnourished

Nutrition Assessment
Purpose : to identify early signs of malnutrition and prevent it from becoming a major co-factor in organ dysfunction and morbidity and mortality

What is Screening?

Separates those who are healthy from those at high risk for the condition Tests should be non-invasive, inexpensive, and have rapidly available results

Screening Tools
MNA Short Form Nutrition Screening Initiative
DETERMINE checklist

MUST (Malnutrition Universal Screening Tool) Nutrition Risk Screening (NRS) (ESPEN)

 Developed in 1990 Validated for ages 65+ Simple, reliable, non-invasive, & quick Inexpensive Validated in hospital & community setting For screening & assessment

Guigoz et al., Nutr. Rev. 1996;54:S59-65 Vellas B et al., J Am Geriatr Soc 2000;48:1300-1309c Rubenstein LZ et al., J Gerontol 2001;56:M366-M372

Validation of

MNA

Nursing home, hospitalized & free living elderly Sensitivity 96% Specificity 98% Predictive value 97% Inter-observer MNA- Kappa 0.51

4 sections: Anthropometrics Diet questionnaire Global assessment lifestyle medications mobility Subjective assessment self perception of health & nutrition

Predictive ability of MNA

One-year Mortality
<17 - 48% 17-23.5 - 24% > 23.5 - 0%

Correlates with functional level Good correlation with nutritional markers

Dietary intake, vit.D, folate, prealbumin

Nutrition Checklist for Older Adults

"DETERMINE" Mnemonic
Name: _____________________ Today's Date: _________

Possible Problem Disease Eating Poorly

Question to Answer I have an illness or condition that made me change the kind and /or amount of food I eat. I eat fewer than two meals per day. I eat few fruits or vegetables, or milk products. I have three or more drinks of beer, liquor or wine almost every day.

YES 2 3 2 2 2 4 1 1 2 1 1

Tooth Loss/Mouth Pain Economic Hardship Reduced Social Contac Multiple Medications Involuntary Weight Loss/Gain Needs Assistance In Self Care Elder Years > Age 80

I have tooth or mouth problems that make it hard for me to eat. I don't always have enough money to buy the food I need. I eat alone most of the time. I take three or more different prescribed or over-the-counter drugs a day. Without wanting to, I have lost or gained 10 pounds in the last six months. I am not always physically able to shop, cook and/or feed myself. Are you over 80 years old?

TOTAL

Scoring
0-2 Good! Recheck your nutritional score in 6 months. 3-5 You are at moderate nutritional risk.
See what can be done to improve your eating habits and lifestyle. Your office on aging, senior nutrition program, senior citizens center or health department can help. Recheck your nutritional score in 3 months.

6 or more
You are at high nutritional risk. Bring this checklist the next time you see your doctor, dietitian or other qualified health or social service professional. Talk with them about any problems you may have. Ask for help to improve your nutritional health.

Nutritional Problem in Older Persons

Malnutrition Obesity

Protein Energy Malnutrition (PEM)

Physiological causes of weight loss : 1. Anorexia of aging
the physiological decrease in appetite and food intake that accompanies normal aging and which may result in undesirable weight loss.

2. Sarcopenia (poverty of flash)

decline in muscle mass and strength .

Non-physiological causes of weight loss

1. 2. 3. 4. 5. Poversty (saving dwindle and earning decrease) Medical illness Social isolation Dementia Dentures and oral health

Management of Under-nutrition
The management strategy employed would vary according to the setting and thet could be tailored for each individual patient. Improve the reversible non-physiological factors Monitoring to ensure improvement in nutritional parameters.

Summary
Changes associated with normal aging increase nutritional risk for older adults. With advancing age, the risk of developing nutritional deficiencies increases. Many older people are at at risk for deficient intakes of some essential nutrients (calories, calcium, vitamin B-6, magnesium and zinc). Generally, nutritional problems are identified using various biochemichal or anthropometric parameters, and immunologic functions.