235 - Ch. 13

Arthritis

-A leading cause of functional limitation among older adults -Osteoarthritis (OA) is associated with aging and normal "wear and tear" on joints. -Knee is the most commonly affected joint. -Excess body weight is the greatest known modifiable risk factor. -Other risk factors for OA include genetics, age, ethnicity, gender, occupation, exercise, trauma, and bone density. -Symptoms of OA usually appear after the age of 45 and by 65 years of age or above. -Objective of treatment is to control pain, improve function, and reduce physical limitations (exercise improves strength, joint stabilizatoin, improves pain, improves fx)

Preventing malnutrition

-A quality of life issue -Commercial supplements are often given between meals. -Potential benefits must be weighed against the potential negative consequences. -Increase of nutrient-dense foods included in diet -Oral supplments, not long term (supplement short term, turns into just giving boost)

Nutrition for adults and older adults

-Adulthood represents a wide age range from young adults at 18 to the "oldest old." -Adults over 50, and especially those over 70, have different nutritional needs than do younger adults.

Functional limitations

-Aging causes a progressive decline in physical function. -Major causes of functional limitations among older adults include --Arthritis --Osteoporosis --Sarcopenia

Aging and older adults

-Aging is a gradual, inevitable, and complex process. -Eventually leads to impairment of organs, tissues, and body functioning -Some changes have nutritional implications. -How and why aging occurs is unknown. -Most theories are based on genetic or environmental causes. -Muscle decreases, fat increases, BMR decreases, P.A. decreases, peristalsis decreases, loss of teeth, vision and hearing loss, sense of smell decreases, lose taste buds

Nutrient and food intake of older adults

-As calorie needs decrease with aging, so does the quantity of food eaten and the amount of calories consumed. -Mean calorie intake falls by 1000 to 1200 cal/day in men and 600 to 800 cal/day in women. -Nutrients with mean intakes less than the DRI --Vitamin E, magnesium, fiber, calcium, and potassium -Problems: live alone (won't eat), problems chewing, decreaesd taste and smell, ability to preprae food

Osteoporosis

-Bone remodeling (decrease in bone mass) -Most at risk - women, white, postmenopausal, no children, smoking, small frame, chronic low calcium -After menopause, women experience rapid bone loss related to estrogen deficiency. -Process actually begins early in life. -Interventions implemented late in life can effectively slow or halt bone loss. -Exercise - yoga; increase calcium supplements with Vit D -Around age 30, peak bone mass is attained

Liberal diet approach (cont.)

-Can be modified to meet the needs of residents with increased needs -Foods may be made more nutrient dense. -Supplemental vitamin C and zinc may be ordered to promote healing. -Frequent and accurate monitoring of the resident's intake, weight, and hydration status is vital.(see if drinking enough, what eating, activity level)

Nutrient and food intake of older adults (cont.)

-Consume less fruit and vegetables (choose dishes w/ veg, add salad; low in fiber, calcium, iron - throw in orange sllices); stir fry, kabobs -Older adults need to improve their intakes of --Whole grains --Dark green and orange vegetables --Dried peas and beans --Fat-free and low-fat milk and milk products -Snacking in older adults may help ensure an adequate intake.

Sarcopenia

-Defined as loss of skeletal muscle mass and strength and function (muscle mass decreases, fat incresases; lose wt, actually losing muscle not fat) -Adv. sarcopenia is cha. by frailty, increased falls, impaired abiliity to perform ADL, diminished QOL -Chronic muscle loss is estimated to affect 30% of people over the age of 60 and may affect more than 50% of those over 80 years of age. -Related to a sedentary lifestyle and less than optimal diet -Strength training using progressive resistance is the best intervention shown to slow down or reverse sarcopenia. -Adequate protein intake is also essential (0.8 not enough, 1.5 g/kg/dau or double)

MyPlate for older adults

-Designed to help healthy, older adults who are living independently choose a diet that is consistent with the Dietary Guidelines for Americans, 2010 -2 things to reduce: calorie needs, empty calories

Alzheimer's disease (cont.)

-Development of AD may also be related to oxidative stress. -People who eat fish have less cognitive decline than people who do not eat fish. --DHA, an omega-3 fatty acid, may offer some protection against AD. -AD can have a devastating impact on an individual's nutritional status.

Screening criteria for malnutrition in older adults

-Disease (2 main: arthritis, AD) Do you have an illness that makes you change the kind and/or amount of food you eat? -Eating poorly Do you eat fewer than two meals a day? Do you eat few fruits, vegetables, or milk products? Do you have three or more drinks of beer, liquor, or wine almost every day? (worried about absorption of vitamins) -Tooth loss/mouth pain Do you have tooth or mouth problems that make it hard for you to eat?

Social isolation

-Eating alone is a risk factor for poor nutritional status among older adults. -Congregate meals -Meals on Wheels -Modified diets, such as diabetic diets and low-sodium diets, are provided as needed.

Screening criteria (cont.)

-Economic hardship Do you sometimes not have enough money to spend on the food you need? -Reduced social contact Do you eat alone most of the time? -Multiple medications Do you take three or more prescribed or over-the-counter drugs a day? (cognitive, not eating, nutrient def.) -Involuntary weight loss/gain - Have you gained or lost 10 pounds in the last 6 months without trying? -Needs assistance in self-care - Are you sometimes not physically able to shop, cook, and/or feed yourself? -Elder years above age 80 - Are you older than age 80?

Healthy aging

-Genetic and environmental "life advantages" have positive effects on both length and quality of life (may not prod. as much cholesterol, metabolism, intelligence, motivation, socialization, avail. of health care, sleep, rest, P.A., health eating -Exericise - 2 and a half hours of mod.intensity per week, 1 hr and 15 min of vigorous aerobic; muscle strengthening at least 2 days -Preventing disease is the key to healthy aging. -Good nutrition -Exercise -Evidence shows that initiating healthy changes even in one's 60s and 70s provides definite benefits.

Liberal diet approach

-Healty diet of nurtient dense foods that contain neither excess. not restrictive amts. of fat, cholesterol, sugar and sodium -Holistic approach is advocated. (find out goals of pt, give freedom nad choices, eval. risks and benefits of doing something -Low-sodium diets used in the treatment of hypertension are often poorly tolerated by older adults. -Imposing dietary restrictions on long-term care residents with diabetes is unwarranted. )reg. diet, consistent in amt. and timing of carbs) -Epidemiologic studies indicate that the importance of hypercholesterolemia as a risk factor for CHD decreases after age 44 and virtually disappears after the age of 65.

Aging demographics (cont.)

-Heterogeneous group -Varies in age, marital status, social background, financial status, living arrangements, and health status -Approximately 80% of adults older than 65 years of age have one chronic health problem. -People define wellness and illness differently as they age; may accept changes in health as normal aspect of aging

Vitamin and mineral supplements

-In theory, older adults should be able to obtain adequate amounts of all essential nutrients through well-chosen foods. -Fifty percent of older adults have inadequate intakes of vitamin E and magnesium. -Supplements tend to have a positive impact on nutritional adequacy for adults age 51 years and older. -After 51, supplement Vit B1, B2, B12, folate, Vit D (food preferred rather than multivitamin)

Downhill spiral (cont.)

-Intake assessment system is flawed. -Food intake records may be neglected. -Lack of skill in accurately judging the percentage of food consumed -A practical approach to convert individual item estimates into meaningful estimates not assessed.

Nutritional needs of older adults

-Knowledge growing -Health status, physiologic functioning, physical activity, and nutritional status vary more among older adults (especially people older than 70 years of age) than among individuals in any other age group. -Calorie needs decrease yet vitamin and mineral requirements stay the same or increase. -Two DRI groupings exist for mature adults. --People age 51 to 70 --Adults over the age of 70

Downhill spiral

-Loss of appetite is a major cause of undernutrition in long-term care. -Undernutrition increases the risk of illness and infection. Infection dev., metabolic rate increases, increased need for calorie and protein. -Undernutrition is exacerbated and a downward spiral ensues. -Minimum Data Set (MDS) requires food intake be assessed so that residents at risk from inadequate intake are identified. Assess food items on meal tray as whole and assign percentage to amt. eaten.

Obesity

-Major public health problem; ass'd with other comorbidities -Risk factor for increased hypertension, insulin resistance, coronary artery disease, OA -Tell to exercise, watch what eating (portion sizes) -Appropriateness of treating obesity in older adults is controversial. -Weight loss can be harmful to older adults. -Goal of weight loss therapy for older adults should be to improve physical function and quality of life.

Alzheimer's disease

-Most common form of dementia in the United States, it affects an estimated 5.1 million Americans. -Risk of AD increases with increasing age. -Cause of AD is unknown and there is no cure. -Genetic and nongenetic factors (e.g., inflammation of the brain, stroke) have been identified in the etiology of AD. -Disruption bw nerve cells in body; plaques build up (beta amyloid) - indissolvable proteins

Vitamins and minerals

-Most recommended levels of intake for vitamins and minerals do not change with aging. -Significant exceptions --Calcium (dark green leafy veg. and legumes) --Vitamin D (milk, fortified cereals, fatty fish) --Iron for women -red meat, o juice w/nonheme -DRI for sodium decreases. -People over 50 are advised to consume most of their B12 requirement from fortified food or supplements. -Def: Vit A, D, E, calcium, magnesium, potassium, fiber (sodium high)

Calories

-Needs decrease with age (have decrease in P.A.); also have decrease in muscle and decrease in BMR -Metabolic rate goes down 2% per decade starting at 30 -Changes in body composition -Physical activity progressively declines. -Estimated 5% decrease in total calorie needs each decade -Undesirable consequences of aging can be improved or reversed with approp. weight training exercises

Nutrition screening for older adults

-Older adults at greatest risk of consuming an inadequate diet are those who are --Less educated --Live alone --Have low incomes -Identifying nutritional problems in older adults can be a challenge. -Anorexia of aging - natural decrease in food intake that occurs even in healthy older adults in repsonse to decrease in P.A. and metabolic rate

Aging demographics

-Older adults, especially those older than 85, represent the fastest growing segment of the American population. -Life expectancies at both 65 and 85 years have increased. -Women and men who live to age 65 can expect to live an average of 19.2 more years. -For those who live to age 85 --Women will survive an average 7 years more. --Men will survive an average 5.9 years more.

Long-term care

-Residents tend to be frail elderly with multiple diseases and conditions. -Malnutrition has a negative impact on both the quality and length of life and is an indicator of risk for increased mortality. -Additional risks among long-term care residents include --Loss of appetite --Pressure ulcers may be a symptom of inadequate food and fluid intake. --Dysphagia (difficulty swallowing, weakened muscles) --Loss of independence, depression, altered food choices, and cognitive impairments can negatively impact food intake.

Nutrition related concerns in older adults

-Should be client-centered and based on the individual's physiologic, pathologic, and psychosocial conditions -Overall goals of nutrition therapy for older adults --Maintain or restore maximal independent functioning and health --Maintain the client's sense of dignity and quality of life by imposing as few dietary restrictions as possible (no restrictions, increases desire)

Fiber

-The AI for fiber is based on median intake levels observed to protect against coronary heart disease. -AI for fiber is 38 g/day for men through age 50 years and 30 g/day thereafter. -AI for fiber is 25 g/day for women from 19 to 50 years of age and 21 g/day thereafter. -AI for fiber is set at 14 g/1000 cal of intake -Increasing intake may help prevent constipation, improve glycemic control, reduce serum cholesterol

Water

-The AI for water is constant from 19 years of age through age 70 and above; men - 3.7 L/day, women - 2.7 L/day -Represents total water intake -Elderly are able to maintain fluid balance. -Altered sensation of thirst and an age-related decrease in the ability to concentrate urine increases risk for --Dehydration --Hyponatremia -Dehydration can contribute to constipation, cognitive impairment, fx decline, death (want to increase fluid, fiber, and activity) -Causes: impaired sensation, meds (diuretics, antidepressants, pain meds, kidney disease, heart disease), impaired mobility, decrease in conc.

Protein

-The RDA for protein remains constant at 0.8 g/kg for both men and women from the age of 19 and older. -Evidence suggests that older adults need more protein than younger adults and that protein intake b/w 1.0-1.6 g/kg/day is safe an adequate to meet needs of healthy older adults (increase if need more protein for sarcopenia or wound healing) -Estimated that 7.2% to 8.6% of older adult women consume protein below their estimated average requirement.

Use of diets

-Use of restrictive diets as part of medical care in long-term care facilities is controversial (personal choices go away) -Diabetics - used to say no conc. sweeets, now carb. or cal controlling -Goals of preventing malnutrition and maintaining quality of life are of greater priority. Restrictive diets -Potential to negatively affect quality of life -Should be used only when a significant improvement in health can be expected

Protein (cont.)

Factors that may contribute to a low protein intake -Cost of high-protein foods -Decreased ability to chew meats -Lower overall intake of food -Changes in digestion and gastric emptying Groups at risk for inadequate protein intake -Oldest elderly -Those with health problems -Those in nursing homes