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MerjaSuominen

Nutritional Disorders in the Elderly

Essentials

  • Deterioration of the nutritional status in an elderly person should be identified. Clinical findings alone are not sensitive indicators of malnutrition.
  • Sufficient intake of energy, proteins and other nutrients through diet should be guaranteed.
  • An overweight person less than 75 years of age may slim with caution if he/she has comorbidities. Patients aged over 75 years rarely benefit from slimming programmes.
  • Vitamin D intake 10 µg (400 IU) daily throughout the year is recommended for persons aged over 60 years and 20 µg (800 IU) for persons aged over 75 years, primarily from the diet, and - if necessary - as vitamin supplementation http://www.dynamed.com/drug-review/vitamin-d-intake-and-supplementation#GUID-52FAFBE1-82D0-41DF-91B0-D02CA832A53F. This may not be applicable in some countries due to environmental differences (sunlight, diet): check the national recommendations.

In principle

  • An elderly patient with poor nutritional status and malnutrition is likely to suffer from a chronic illness. Health care providers should address poor nutritional state in an elderly patient more vigorously than is the current practice.
  • The nutritional state of an elderly person should be assessed and monitored e.g. by changes in body weight http://www.dynamed.com/evaluation/dietary-assessment-in-adults. The Mini Nutritional Assessment (MNA) test http://www.mna-elderly.com is useful in institutions and in home care.
    • An overweight elderly person may also have malnutrition (fat frail).
  • Dietary treatment may be used to maintain good nutritional status and adequate body weight, to prevent weight loss and to promote functional capacity and quality of life.
    • A low body mass index (BMI) and unintentional weight loss increase morbidity and mortality.
    • Sufficient intake of energy and proteins should be guaranteed. It is important to maintain good muscular strength and prevent the progression of sarcopenia.
    • The recommended daily intake of protein from food is at least 1.2-1.4 g/kg body weight http://www.dynamed.com/prevention/geriatric-health-maintenance#DIET_AND_NUTRITION.
      • According to recent research, only 25% of elderly persons have a daily intake of protein at least 1.2 g/kg body weight.
    • In association with muscle conditioning exercise, daily protein intake of 1.3 g/kg body weight has been shown to be beneficial.
    • Weight reduction should be cautious in the elderly. Weight loss and alternating weight easily lead to muscle wasting and relative increase of fat tissue.
    • In a patient aged less than 75 years and with a BMI of over 30, cautious weight reduction with the aid of increased physical exercise together with ensuring of sufficient protein intake is feasible in the treatment of diabetes, cardiac insufficiency, hypertension and osteoarthritis. Otherwise, being moderately overweight (BMI 24-29) is rarely an indication for treatment in an elderly patient.
  • Recommendation for vitamin D intake: see Essentials. For the prevention of fall-induced fractures the minimum dose of vitamin D has been 700-800 IU (17.5-20 µg). For the prevention of osteoporosis, an adequate intake of calcium (800-1 500 mg/day) primarily through diet must also be ensured.
  • If an elderly patient presents with vitamin B12 or iron deficiency, gastrointestinal problems should be considered.
  • Routine use of vitamins or minerals has not been proven effective.

Prevalence of malnutrition

  • In the Western world, the prevalence of malnutrition among the elderly population is 5-10%.
    • 10-20% among patients aged over 80 years
    • 27-65% among hospitalised patients
    • 30-80% among patients in institutional care

Predisposing factors

  • Problems in obtaining food
    • Financial (small pension, unwillingness to spend money on food)
    • Problems with mobility, reduced functional capacity, lack of personal help
    • Clinging to old habits, alcoholism
  • Difficulty with chewing and swallowing
    • Stroke, dementia, Parkinson's disease, missing teeth, painful mouth
  • Increased nutritional requirements, especially for proteins
    • Infections, pressure sores
    • Trauma, surgery, particularly patients with hip fractures
    • Sarcopenia
  • Wasting diseases
    • Cancer, chronic infections (tuberculosis etc.)
    • Alzheimer's disease, other memory diseases
  • Impaired utilization of nutrients
    • Malabsorption (intestinal disorders, coeliac disease)
  • Others
    • Psychological causes (depression, paranoia, mania)
    • Drug treatment causing decreased appetite, dry mouth, changes in taste or smell
    • Impaired sense of taste or smell
  • Physiological changes related to ageing http://www.dynamed.com/condition/frailty-in-older-adults
    • Decreased basal metabolic rate, sarcopenia and reduced physical activity will lessen the need for energy, and the daily calorie intake of elderly women will often remain below the recommended 1 600 kcal.
    • Delayed gastric emptying; energy-rich metabolism products (glucose, free fatty acids) will remain longer in the circulation, thus prolonging the feeling of satiety.
    • Muscle tissue is always lost with aging and the proportion of adipose tissue increases.
    • Reduced glucose tolerance
    • Susceptibility to disorders in fluid balance

Consequences of malnutrition

  • Morbidity and mortality increase.
  • Delayed recovery from illnesses
  • Prolonged hospitalisation, increased demand for health services
  • Impaired resistance, slower wound healing, increased risk of infections
  • Accelerated muscular wasting, diminished muscle function and strength, increased risk of falls and fractures

Diagnosis of malnutrition

  • Clinical findings are not sensitive indicators of impaired nutrition.
  • The most commonly used indicators are: unintentional weight loss, low body weight or BMI, poor wound healing, triceps muscle skinfold thickness and midarm circumference, serum albumin, haemoglobin and lymphocytes, detailed scrutiny of the diet, ability to obtain and prepare food, intake of vitamins, clinical examination.
  • Deterioration of the nutritional status is generally poorly recognized.

Treatment of malnutrition

  • The aim of dietary treatment in an elderly patient is to safeguard an adequate intake of calories, especially proteins and other nutrients as well as to maintain an adequate nutritional state http://www.dynamed.com/condition/unintentional-weight-loss-in-older-adults#DIET.
  • The elderly and ill population is especially affected by protein-calorie malnutrition, which warrants more vigorous attention than is the current practice.
  • Nutritional supplementation appears to reduce mortality and complications .
  • A diet enhanced by energy and proteins secures an adequate energy and protein intake for an elderly person better than a conventional diet.
  • Family style mealtimes in care institutions improve the quality of life and increase the intake of calories and nutrients.
  • The eating habits of an elderly person living at home should be checked; food delivery services may be considered, particularly after discharge from hospital.
  • An elderly person's daily intake of protein should be 1.2-1.4 g per kg of body weight http://www.dynamed.com/prevention/geriatric-health-maintenance#DIET_AND_NUTRITION. The requirement increases during illness.
  • The proportion of protein and the nutrient density in the diet should increase with advancing age.

Other common nutritional disturbances

References

  • Baldwin C, Kimber KL, Gibbs M ym. Supportive interventions for enhancing dietary intake in malnourished or nutritionally at-risk adults. Cochrane Database Syst Rev 2016;12():CD009840. [PubMed]
  • Tieland M, Dirks ML, van der Zwaluw N et al. Protein supplementation increases muscle mass gain during prolonged resistance-type exercise training in frail elderly people: a randomized, double-blind, placebo-controlled trial. J Am Med Dir Assoc 2012;13(8):713-9. [PubMed]
  • Jyväkorpi S. Nutrition of older people and the effect of nutritional interventions on nutrient intake, diet quality and quality of life. Doctoral dissertation. University of Helsinki, 2016 http://urn.fi/URN:ISBN:978-951-51-2019-9.
  • Puranen T. Intervening nutrition among community-dwelling individuals with Alzheimer's disease and their spouses. Doctoral dissertation. University of Helsinki, 2015 http://urn.fi/URN:ISBN:978-951-51-1755-7.
  • Vitality in later years : food recommendation for older adults. National nutrition council and Finnish Institute for Welfare and Health. THL Directions 9/2020 http://urn.fi/URN:ISBN:978-952-343-517-9.