Download Nutrition Support for the Elderly

G. Meinhold
Fall 2014
Nutrition Support for the Elderly
Medical technologies continue to evolve, and the possibilities of improving quality of life for the aging
population are promising. Stem cells, organ transplantations, new pharmacological treatments, etc. are
all expected to benefit the health of the aging population which will also lead to the expanded use of
nutrition support. This handout reviews the indications for nutrition support, the different types of
nutrition support, and ethical issues. In the end, the patient and his or her family should be part of the
decision-making process.
Nutrition Support involves the provision of nutrition beyond that provided by normal food intake. It is
used for people who cannot get enough nourishment by eating or drinking such as people who can't
swallow, have problems with appetite, are severely malnourished, or can't absorb nutrients through the
digestive system.
Nutrition support can be provided three ways: 1) orally through supplements, 2) with a feeding tube that
goes into the intestinal tract (enteral feedings), or 3) through a needle or catheter placed in a vein
(parenteral feedings.)
Defining Malnutrition in the Context of Illness and Aging:
In general, older adults tend to consume fewer calories. Most 70-year-olds consume one-third fewer
calories than the RDA, and 16% to 18% of older adults consume fewer than 1,000 calories per day.
Decreased oral intake can ultimately progress to weight loss and malnutrition. A 2010 study published
in the Journal of the American Geriatrics Society found that older adults are at risk for malnutrition, with
39% to 47% of hospitalized older adults malnourished or at risk for malnutrition.1 Older adults are at risk
for malnutrition due to dietary, economic, psychosocial, and physiological factors.
1. Dietary intake:
a. Little or no appetite.
b. Problems with eating or swallowing.
c. Eating inadequate servings of nutrients.
d. Eating fewer than two meals a day.
2. Limited income may cause restriction in the number of meals eaten per day or dietary quality of meals eaten.
3. Isolation:
a. Older adults who live alone may lose desire to cook because of loneliness.
b. Appetite of widows decreases.
c. Difficulty cooking due to disabilities.
d. Lack of access to transportation to buy food.
4. Chronic Illness:
a. Chronic conditions can affect intake.
b. Disability can hinder ability to prepare or ingest food.
G. Meinhold
Fall 2014
c. Depression can cause decreased appetite.
d. Poor oral health (e.g., cavities, gum disease, and missing teeth) and xerostomia (dry mouth) can impair
the ability to lubricate, masticate, and swallow food.
e. Antidepressants, antihypertensives, and bronchodilators can contribute to xerostomia.
5. Physiological changes:
a. Decrease in lean body mass and redistribution of fat around internal organs lead to decreased caloric
requirements.
b. Change in taste (from medications, nutrient deficiencies, or tastebud atrophy) can also alter nutritional
status.
The DETERMINE Checklist Developed by the American Academy of Family Physicians, Academy of
Nutrition and Dietetics, and National Council on Aging remains one of the best assessment tools, along
with physical assessments. The checklist integrates a list of warning signs of poor nutritional health in
older adults such as food intake, tooth loss, economics, social contact, medications, BMI, history of
weight loss, self-care, age, psychological stress, or acute disease and dementia or other psychological
conditions. Refer to the separate NSI-DETERMINE handout.
Indications for Nutritional Support:
G. Meinhold
Fall 2014
Types of Nutrition Support:
The optimal method for nutritionally supporting patients who are at risk for malnutrition is to feed them a
nutritionally dense, well-balance diet. Patients should be encouraged to eat as much as possible within
the limits for their disabilities, oral health status, and medical conditions. However, many older patients
do not meet their nutrient requirements. One study conducted as an observational longitudinal cohort
survey followed elderly people living in their communities and noted that oral nutritional supplements
improved health status.2
Oral Supplements (or commercial liquid supplements) are available today in a wide variety and in
an assortment of flavors. They are commonly used in hospitals and other health care institutions to
increase calories and protein intake. Many are also easily accessible in drug stores and grocery stores.
Disease-specific oral supplements are also available for people with diabetes, chronic kidney disease,
and disorders of the small bowel.
If a patient can safely swallow, the first option should be an oral liquid supplement. Oral supplements
can play a significant role in the prevention of malnutrition in both free-living and institutionalized older
adults. Studies suggest that nutrition supplementation in older adults can lead to significant
improvements in nutritional status, increased calorie and protein intake, and improvement in body
weight, as well as a decreased utilization of health care services.
Enteral Feedings is nutrition provided by a tube. There are three main feeding routes to choose from:
nasogastric feedings, gastric feedings (gastrostomy), and jejunal feedings (jejunostomy.) Choosing the
proper feeding delivery route is important and the planned duration of feeding as well as the patient’s
diagnosis and personal preferences often determines the route. The most common feeding
administration route in geriatric patients is nasogastric feeding.
G. Meinhold
Fall 2014
Selection of Enteral Formulas. There are many formulas available for enteral nutrition,
accommodating virtually every disease state and nutrition need. The nutrient composition of standard
enteral formulas varies from product to product and it is usually a health-care provider (Registered
Dietitian, Nutritionist) that chooses the appropriate enteral formula. Recent research has focused on the
use of prebiotics and fiber in enteral formulas to assist with controlling blood glucose and lipid levels, as
well as aid with constipation.
Parenteral Nutrition is the intravenous provision of nutrients via a central (large, usually the vena
cava) or peripheral (hand or forearm) vein. Total parenteral nutrition (TPN) should be used when
enteral feedings is not an option. In most cases it is used when one does not have a functional
gastrointestinal tract. Common uses for TPN include short bowel syndrome, ileus, severe malnutrition,
bowel obstruction, massive gastrointestinal bleeding, intractable diarrhea, and vomiting. Micronutrients
and macronutrients (in the form of glucose, amino acids, and fatty acids) are delivered directly into the
vein to meet the patient’s nutrient requirements.
Ethical Issues:
Attention has been brought to the issues surrounding tube feedings and hydration in patients who are
cognitively impaired or incompetent or are unable to express their wishes. Providing or withholding
nutrition in severely disabled elderly persons is a challenging dilemma for families, health professionals,
and institutions. Despite limited evidence that nutrition support improves functional status in vulnerable
older persons, especially those suffering from dementia, the issue of nutrition support in this population
is strongly debated. Nutrition might be considered a basic need that not only sustains life but provides
comfort to patients as well as their families. Consequently, the decision to provide or withhold nutrition
support during medical care is often complex and involves medical, legal, and ethical aspects, which
sometimes contributes conflicting opinions about what can or should be done in any specific case.
This reminds us all that discussions about end-of-life decisions, advance directives, living wills and
durable power of attorney should be held while individuals are still healthy and mentally competent.
Refer to the article from Today’s Dietitian, “Nutrition Support at the End of Life: A Critical
Decision.”
References
1. Kaiser, M.J., Bauer, J.M., Rämsch, C., Uter, W., Guigoz, Y., Cederholm, T.,...Siber, C.C. (2010). Frequency of malnutrition
in older adults: A multinational perspective using the mini nutritional assessment. Journal of the American Geriatrics Society,
58, 1734-1738.
2. Arnaud-Battandiet F, Malvy D, Jeandel C, et al. Use of oral supplements in malnourished elderly patients living in the
community: a pharmaco-economic study. Clin Nutr. 2004; 23:1096-1103.