Nutrition and Older People

Nutricia

Outline

• Introduction

• Definition

• The ageing population

• The ageing process

• Nutritional requirements in older people

• Malnutrition in older people

• Prevalence

• Causes

• Consequences

• Managing malnutrition in older people

• Summary

1 Introduction

Definition

• There is no one universally accepted definition for when someone

can be classified as an older adult

• This presentation will focus on those over 65 years of age

1. NICE Clinical Guideline 161, 2013. 2. Deutz, et al. Clin Nutrr. 2012;33:929-36. 3. http://www.who.int/healthinfo/survey/ageingdefnolder/en/. Mar 16, 2016.

NICE1

65 and older

ESPEN2

Older adults above 65

WHO3

Use 50 years and over as the definition of an older

person

The ageing population

• Since 1974 the median age of the UK population has increased

from 33.9 years to 40.0 years1

• In 2014 it was estimated 11.4 million people (17.6% of the

population) was over 651:

• This is an increase from 13.8% in 1974 and 15.8% in 20001

• It’s projected the percentage of the population over 65 will

increase by between one fifth and one quarter by mid 20222

1. http://webarchive.nationalarchives.gov.uk/20160105160709/http://www.ons.gov.uk/ons/rel/pop-estimate/population-estimates-for-uk--england-and-wales--scotland-and-northern-ireland/mid-2014/sty-ageing-of-the-uk-population.html. Apr 4, 2016. 2. http://webarchive.nationalarchives.gov.uk/20160105160709/http://www.ons.gov.uk/ons/rel/snpp/sub-national-population-projections/2012-based-projections/stb-2012-based-snpp.html. Apr 4, 2016.

9.6% of the

population are

aged 65-74

5.7% of the

population are

aged 75-84

2.3% of the

population are

aged 85 and

over

The Ageing Process

Source: Gandy J. Manual of Dietetic Practice. Wiley Blackwell Publishing, 2014

Part of body Changes produced by ageing

Skin Reduced strength & elasticity, increased susceptibility to damage, prolonged wound

healing, reduced synthesis of Vitamin D

Heart Loss of heart muscle; decreased cardiac output

Renal function filtration rate & glucose threshold

Bone ↑ resorption, osteoporosis

Immune system Impaired T cell function leading to increased infection risk

Intestine motor function & muscle tone, impaired digestive capacity, diverticula

Muscle Sarcopenia which reduces functional capacity

Hearing Loss of perception of high frequencies

Pain & touch Touch & pain thresholds increase

Taste & smell Loss of taste sensitivity (↓ number of taste buds)

Vision visual acuity, decreased peripheral vision

Body composition Decreased strength & physical fitness, loss of muscle and bone strength

Nervous System Decreased brain mass, loss of neurones, slower thought process & reaction times

• Ageing is a natural process but it has many effects on the body

2

Nutritional Requirements in

Older People

Nutritional Requirements

• It’s important to remember that older adults, like most other age

groups, are a diverse group and therefore their nutritional needs

vary

• Reduced appetite and intake can occur as a result of age related

changes

• Energy requirements reduce slightly with age, however

micronutrient requirements remain the same, and protein

requirements may increase

• The elderly are therefore at risk of inadequate intakes of many

nutrients

• Of most concern are energy, protein, vitamin C, vitamin D, folate,

iron, zinc and fibre

Source: Gandy J. Manual of Dietetic Practice. Wiley Blackwell Publishing, 2014

Energy Requirements

Age Weight (kg) EAR (kcal/day)*

Men

65-74 years 71.0 2330

75+ years 69.0 2100

Women

65-74 years 63.0 1900

75+ years 60.0 1810

Source: Department of Health. Dietary Reference Values for Food Energy and Nutrients for the United Kingdom 41, HMSO, London, 1991.

*EAR calculated using BMR x 1.5 physical activity level (PAL)

Energy Requirements

• Some older people may need to consume more energy dense

food and fluids to combat a reduce appetite and decline in intake

• While others that don’t experience a reduction in appetite and

intake should follow the usual healthy eating principles

• Furthermore the elderly are at higher risk of age related diseases

such as stroke, dementia and cancer, which may affect their

energy requirements

Source: Gandy J. Manual of Dietetic Practice. Wiley Blackwell Publishing, 2014

Protein Requirements

Guidelines for Estimating Protein Requirements

• The RNI for healthy adults (both male and female) aged 50+ years

is estimated at 0.75g protein/kg of body weight per day1

―A male 50+years (70kg) the RNI for protein is approximately

53g/day

• The World Health Organisation (WHO) recommend that healthy

older people need 0.9-1.1g protein/kg body weight per day2

―A male 50+years (70kg) the WHO recommendation for protein is

63-77g/day

1. Department of Health. Dietary Reference Values for Food Energy and Nutrients for the United Kingdom 41, HMSO, London, 1991. 2. World Health Organization. Keep fit for life: Meeting the nutritional needs of older persons, WHO library, 2002.

Estimating Protein Requirements

Revision of Protein Requirements by the ESPEN Expert Group

• Protein intake for optimal muscle function with aging:

―1.0-1.2 g protein/kg body weight/day for healthy older adults

―1.2-1.5 g protein/kg body weight/day may be indicated for

certain older adults who have acute or chronic illnesses

―Even higher intake for individuals with severe illness or injury

• A male 50+years (70kg) the ESPEN recommendation for protein

is:

―70-84g/day (healthy)

―84-105g/day (acute or chronic illness)

Source: Deutz et al. Clin Nutr. 2014;33:929-36.

Estimating Protein Requirements

Key conclusions from the ESPEN Expert Group

• “Good nutrition, especially adequate protein intake, also helps

limit and treat age-related declines in muscle mass, strength, and

functional abilities.”

• “Older adults need high protein intake to sustain healthy aging

and longevity”

• “In order to help prevent or delay adverse consequences, we

encourage increased intake of dietary protein for older adults (65

years)”

Source: Deutz et al. Clin Nutr. 2014;33:929-36.

Estimating Protein Requirements

52.5

63-77

70-84

84-105

0

10

20

30

40

50

60

70

80

90

100

110

RNI WHO ESPEN (Healthy) ESPEN (Illness)

Pro

tein

(g/d

ay)

*

Up to 52.5g deficit during illness

when compared to ESPEN

recommendations

1. Department of Health. Dietary Reference Values for Food Energy and Nutrients for the United Kingdom 41, HMSO, London, 1991. 2. World Health Organization. Keep fit for life: Meeting the nutritional needs of older persons, WHO library, 2002. 3. Deutz et al. Clin Nutr. 2014;33:929-36.

*based on a 50+ year old male who weighs 70kg

1 2 3 3

Fluid Requirements

• Dehydration is common in older people1:

• 10% of those admitted to community hospitals

• 25% of those who are immobile

• Dehydration may occur due to a number of causes including1:

• Pathophysiological – confusion, drowsiness, decreased mobility/dexterity

• Ageing – reduced thirst, increased skin losses, reduced renal function

• Iatrogenic – drugs, fluid restriction, institutionalisation, urinary incontinence

• There is no standard fluid requirement for older adults in the UK, the

following are suggested for all adults:

PENG2

25-35ml/kg/day in health

NICE3

30-35ml/kg/day

Manual of dietetic practice1

1500-2000ml/day

1. Gandy J, Eds. Manual of Dietetic Practice. 5th edn. Wiley Blackwell Publishing, 2014 2. Todorovic VE, et al. A pocket guide to clinical nutrition. 4th ed. British Dietetic Association, 2011. 3. NICE. Clinical Guideline 32, 2006.

Fibre Requirements

• According to the 2015 Scientific Advisory Committee on Nutrition

Carbohydrate and Health report all adults are recommended to

consume 30g/day of fibre

• The recommendations do not differ for younger and older adults

• Sources of fibre include wholegrain breads and cereals, fruit,

vegetables, pulses and nuts.

Source: Scientific Advisory Committee on Nutrition. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/445503/SACN_Carbohydrates_and_Health.pdf [13.04.2016]

Micronutrient requirements

Micronutrient RNI Function Deficiency Sources

Vitamin C 40mg/day for men and

women 50+ years

Wound healing,

aids absorption of

iron, antioxidant

Poor wound

healing

Fruits and

vegetables

Vitamin D 10μg/day for men and

women 65+ years

Calcium

homeostasis

Rickets,

osteomalacia

Sunlight, oily fish,

eggs, fortified

margarine

Folate 200μg/day for men

and women 50+ years

Required for

formation of red

blood cells

Megaloblastic

anaemia

Pulses, fortified

breads and

cereals,

vegetables, fruit

Iron 8.7mg/day for men

and women 50+ years

Crucial for red

blood cell function

Anaemia Meat, pulses,

nuts, liver,

wholegrain, dark

green leafy

vegetables

Zinc 9.5mg/day for men

and 7.0mg/day for

women 50+ years

Essential for

tissue formation

and wound

healing

Taste changes,

impaired wound

healing, reduced

appetite

Meat, shellfish,

dairy, breads,

cereals

Source: https://cot.food.gov.uk/sites/default/files/vitmin2003.pdf Apr 13, 2016.

3 Malnutrition in Older People

Definition of Malnutrition

‘Malnutrition is a state of nutrition in which a deficiency or excess (or

imbalance) of energy, protein and other nutrients causes measurable

adverse effects on tissue / body form (body shape, size and

composition) and function and clinical outcome.’

• This definition includes both under nutrition and over nutrition

• In this instance the focus is on under nutrition

Source: Elia. http://www.bapen.org.uk/information-and-resources/publications-and-resources/bapen-reports [11.04.2016]

Malnutrition in Older People

• ‘Older people are at risk of malnutrition due to reduced dietary

intake and activity, resulting in changes in body composition.

Physical and mental illness can result in deterioration and lack

of mobility.’1

• The elderly have the highest prevalence of malnutrition:

• Hospital – 33.6% in older adults, 25.1% in <65 and 15% in

children2

• Care homes – 36% in older adults vs. 24% in younger adults2

• Free living – 14% in older people vs. 5% in the general

population3

1. Gariballa, et al. Br J Nutr. 1998;79:481-7. 2. Elia M. http://www.bapen.org.uk/pdfs/economic-report-full.pdf [11.04.2016] 3. Gandy J. Manual of Dietetic Practice. Wiley Blackwell Publishing, 2014

• Availability of food

• Finances

• Reduced ability to cook

• Changes to sensory perception

e.g. taste and smell

• Health issues

Source: Gandy J. Manual of Dietetic Practice. Wiley Blackwell Publishing, 2014

Decreased intake Increased nutritional

needs

Increased nutrient

losses • Poor food provision

• Lack of interest in food

• Oral problems e.g. ill fitting

dentures, dry mouth

• Needing assistance with food

• Bad mealtime experience

Causes of Malnutrition in Older People

Causes of Malnutrition in Older People

Increased nutritional

needs

• Involuntary movements e.g. Parkinson’s Disease or wandering in dementia

• Drug-nutrient interactions

• Illness/disease e.g. COPD, cancer, pneumonia

Source: Gandy J. Manual of Dietetic Practice. Wiley Blackwell Publishing, 2014

Causes of Malnutrition in Older People

Increased nutrient

losses

• Drug-nutrient interactions

• Polypharmacy

• Bacterial overgrowth

• GI losses e.g. vomiting, diarrhoea, fistulae, exudate from wounds or pressure

sores

Source: Gandy J. Manual of Dietetic Practice. Wiley Blackwell Publishing, 2014

Consequences of Malnutrition in Older People

Consequences of Malnutrition

Impaired immune response

Muscle wasting

Reduced respiratory

muscle function

Impaired thermoregulation

Impaired wound healing

Psychological effects

Source: Gandy J. Manual of Dietetic Practice. Wiley Blackwell Publishing, 2014

Identifying Malnutrition – Malnutrition Universal

Screening Tool (‘MUST’)

• The ‘MUST’ is a five step tool used to identify individuals who are

malnourished or at risk of malnutrition

• It gives a score that indicates malnutrition risk using:

• BMI

• Weight loss over the last 3-6 months

• Acute disease effect

• It also has suggested management guidelines based on the

‘MUST’ score

• For more information visit the ‘MUST’ website -

http://www.bapen.org.uk/screening-and-must/must/introducing-

must

Source: BAPEN. http://www.bapen.org.uk/musttoolkit.html [11.04.2016].

Identifying Malnutrition – Malnutrition Universal

Screening Tool (‘MUST’)

4

Managing Malnutrition in Older People

Nutritional Management

• Management of malnutrition in older people will depend on the

setting and extent of malnutrition

• ‘Managing Adult Malnutrition in the Community’ is a pathway

designed to guide the identification and management of

malnutrition in the community1

• Local guidelines and protocols for managing malnutrition should

be followed

• Most management will incorporate a range of strategies this may

include the food first approach, oral nutritional supplements (ONS)

and enteral tube feeding if the patient is unable to consume

adequate amounts orally

1. http://malnutritionpathway.co.uk/downloads/Managing_Malnutrition.pdf [14.04.2016]

Food First Approach

• Incorporates both food fortification and dietary modification

• Food fortification aims to increase the nutrient density of the diet,

but not the volume, through the use of energy rich foods1,2

• Care should be taken when using food fortification as it

supplements energy and/or protein without adequate

micronutrients2

• Dietary modification involves encouraging change to meal

patterns and food choices to encourage greater overall nutritional

intake1,2

1. Gandy J. Manual of dietetic practice. Wiley Blackwell, 2014. 2. NICE Clinical Guideline 32.

Food First Approach

Common food first strategies include:

Encouraging small frequent meals and snacks

Choosing full fat dairy products

Avoiding diet foods and drinks

Fortifying milk by adding four tablespoons of dried milk powder to one pint

of milk and using this throughout the day

Adding cream, cheese, butter, oil, jam, honey and/or syrup to soups,

sauces, vegetables, cereals and desserts

Including nourishing drinks e.g. milk based drinks or powdered oral

nutritional supplements made up with water or milk

Leaving fat on meat and choosing fattier cuts e.g. chicken thigh instead of

chicken fillets

Source: Gandy J. Manual of dietetic practice. Oxford: Wiley Blackwell, 2014.

Oral Nutritional Supplements (ONS)

• ONS are a convenient and easy way of taking a concentrated

source of both macro- and micro-nutrients, for those who are

unable to meet their nutritional requirements by modification of the

normal diet alone

• ONS are available in a variety of formats and styles, including

milkshake-, juice-, yogurt-, and dessert-style, as well as a variety

of flavours to suit different taste preferences

• Most ONS contain ~300kcal, 12g protein and micronutrients,

however there are some that contain extra protein, fibre or other

nutrients such as omega-3 fatty acids

Evidence for ONS

• ONS have been shown to be a cost effective way to manage malnutrition1

• In addition to energy and protein, ONS provide a full range of

micronutrients, unlike food fortification

• ONS have been shown to:

• Have no affect on voluntary food intake2

• Increase energy and protein intakes2-5

• Improve weight2-5

• Reduce complications (e.g. infection, pressure ulcers, poor wound

healing)2,3,5

• Reduce mortality2,3

• Improve strength2,5

• Reduce hospital admissions and readmissions4-6

1. BAPEN. http://www.bapen.org.uk/pdfs/economic-report-short.pdf [14.04.2016] 2. Stratton, et al. Clin Nutr Supp. 2007;2:5-23. 3. NICE Clinical Guideline 32 4. Norman, et al. Clin Nutr. 2008;27:48-56. 5. Cawood, et al. Ageing Res Rev. 2012;11:278-96. 6. Stratton, et al. Ageing Res Rev. 2013;12:884-97.

Enteral Tube Feeding

• Enteral tube feeding is only indicated if a person is unable to meet

their nutritional requirements orally

• The gastrointestinal tract must be functional and accessible

• Enteral tube feeding can be used:

• Short term (<4 weeks) – usually nasogastric feeding tube, or

• Long term (>4 weeks) – usually a gastrostomy tube

• The decision on whether a patient should receive enteral tube

feeding should be made on an individual basis

Summary

• The UK population is ageing, with 17.6% above 65 years old1

• Energy requirements in older people decrease slightly, but

micronutrients requirements remain the same and protein

requirements may increase2

• Older people have higher protein requirements than previously

thought3

• Malnutrition is most common in older people4

• Malnutrition leads to a number of consequences in older people

including decreased immunity, muscle wasting and impaired

wound healing2

• A food first approach, ONS and enteral tube feeding can all be

used to manage malnutrition in older people

• ONS are an evidenced based strategy to improve outcomes in

malnourished older people5

1. http://webarchive.nationalarchives.gov.uk/20160105160709/http://www.ons.gov.uk/ons/rel/pop-estimate/population-estimates-for-uk--england-and-wales--scotland-and-northern-ireland/mid-2014/sty-ageing-of-the-uk-population.html. Apr 4, 2016. 2. Gandy J. Manual of Dietetic Practice. 5th edn. Oxford; Wiley Blackwell Publishing, 2014 3. Deutz et al. Clin Nutr. 2014;33:929-36 4. Elia M. http://www.bapen.org.uk/pdfs/economic-report-full.pdf [11.04.2016] 5. Stratton, et al. Clin Nutr Supp. 2007;2:5-23.

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supplements. Ageing Res Rev. 2012;11:278-96.

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London, 1991.

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[14.04.2016]

Gandy J, Eds. Manual of Dietetic Practice. 5th edn. Oxford: Wiley Blackwell Publishing, 2014

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http://malnutritionpathway.co.uk/downloads/Managing_Malnutrition.pdf Accessed [14.04.2016]

http://webarchive.nationalarchives.gov.uk/20160105160709/http://www.ons.gov.uk/ons/rel/pop-estimate/population-

estimates-for-uk--england-and-wales--scotland-and-northern-ireland/mid-2014/sty-ageing-of-the-uk-population.html.

Accessed Apr 4, 2016.

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tube feeding and parenteral nutrition. NICE Guideline 32 (CG32).

Norman K, Kirchner H, Freudenreich M, et al. Three month intervention with protein and energy rich supplements

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Thank you