nutrition in age

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CHAPTER 21

Nancy S. Wellman, PhD, RD, FADA

Barbara J. Kamp, MS, RD

Nutrition in Aging

KEY T ERMSachlorhydria activities of daily living (ADLs) age-related macular degeneration (AMD) assisted living communities (ALCs) baby boomer cataract diabetic retinopathy dysgeusia dysphagia functionality geriatrics

gerontology glaucoma home- and community-based services (HCBS) hyposmia

instrumental activities of daily living (IADLs) Minimum Data Set (MDS) Omnibus Reconciliation Act (OBRA) one percent rule polypharmacy pressure ulcers presbycusis quality of life Resident Assessment Instrument (RAI) sarcopenia sarcopenic obesity sedentary death syndrome (SeDS)

senescence skilled nursing facility (SNF) supercentenarians xerostomia

THE OLDER POPULATION

Older adults in the United States are living longer, healthier,and more functionally fit lives than ever before. Life expec-

tancy increased by 30 years in the twentieth century. Thoseborn today can expect to live an average of 77.9 years. Women who reach age 65 can expect to live an additional19.9 years, and men, 17.2 years. By the year 2020 the popu-lation older than age 65 will grow from approximately 40million to 55 million, increasing from 13% to 20% of thepopulation. The fastest-growing segment is those older thanage 85, currently almost 6 million and increasing to almost7 million in 2020. Members of minority groups will alsoincrease from 20% to 24% of the older population (U.S.

Administration on Aging [USAoA], 2010). See Figures 21-1and 21-2.

By 2030 the number of older adults will exceed the

number of school-age children in 10 states—Florida, Penn-sylvania, Vermont, Wyoming, North Dakota, Delaware,New Mexico, Montana, Massachusetts, and West Virginia. A few years ago no state had more people older than age65 than those younger than 18. Twenty-six states will doubletheir older-than-65 population by 2030, when the oldest ofthe baby boomer generation enter their 80s. Growth in theolder-than-65 population will equal 3.5 times the U.S.growth as a whole. This demographic shift has enormoussocial, economic, and political implications (He, 2005).

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444 PART 3 | Nutrition in the Life Cycle

20042050 (projected)

Non-Hispanicwhite alone

Asian aloneBlack alone

82

61

12 83 6

18

138

100

90

80

70

60

50

40

30

20

10

0

P e r c e n t

All other racesalone or in

combination

Hispanic(of any race)

homes and communities where the focus is on health pro-motion, risk reduction, and disease prevention.

NUTRITION IN HEALTHPROMOTION AND

DISEASE PREVENTION

In aging nutrition care is not only disease management ormedical nutrition therapy; it has broadened with a strongerfocus on healthy lifestyles and disease prevention. Withoutincreased emphasis on better diets and more physical activ-ity at all ages, health care expenditures will rise exorbitantlyas the population ages. Thus it is never too late to emphasizenutrition for health promotion and disease prevention.Older Americans, more than any other age group, wanthealth and nutrition information and are willing to makechanges to maintain their independence and quality of life. They often need help in improving self-care behaviors. They want to know how to eat healthier, exercise safely, andstay motivated.

Nutrition may include three types of preventive services.In primary prevention, the emphasis is on nutrition in healthpromotion and disease prevention. Pairing healthy eating with physical activity is equally important.

Secondary prevention involves risk reduction and slowingthe progression of chronic nutrition-related diseases tomaintain functionality and quality of life. Functionality isperceived as a positive way to discuss fitness versus disabilityand dependence, because the term exercise is not appealing.

Many community dining centers funded through the Older Americans Act (OAA) Nutrition Programs attract partici-pants through new fitness programs

In tertiary prevention, case management and dischargeplanning often involve chewing and appetite problems,modified diets, and functional limitations. Complicatedcases are often influenced by nutrition issues; case managerscan benefit from consulting with dietitians (see New Direc-tions: Providing Health Care for Older Americans Means Jobs).

THEORIES ON AGING

Gerontologists study aging and have diverse theories about why the body ages. No single theory can fully explain thecomplex processes of aging. A good theory should integrate

knowledge and tell how and why phenomena are related.Broadly, theories can be grouped into two categories: pre-determined and accumulated damage. A loss of efficiencycomes about as some cells wear out, die, or are not replaced. This is sometimes referred to as the one percent rule ; mostorgan systems lose approximately 1% of their functioningeach year, starting at age 30. A recent theory is that the causeof age-related health decline is malfactioning telomeres. Sofar the studies are in mice (Sahin et al., 2011). Most likelyseveral theories explain the heterogeneity in older popula-tions. See Table 21-1.

PHYSIOLOGIC CHANGES

Aging is a normal biologic process. However, it involvessome decline in physiologic function. Organs change withage. The rates of change differ among individuals and withinorgan systems. It is important to distinguish between normalchanges of aging and changes caused by chronic disease suchas atherosclerosis.

The human growth period draws to a close at approxi-mately age 30, when senescence begins. Senescence is theorganic process of growing older and displaying the effectsof increased age. Disease and impaired function are notinevitable parts of aging. Nevertheless, there are certainsystemic changes that occur as part of growing older. Thesechanges result in varying degrees of efficiency and func-

tional decline. Factors such as genetics, illnesses, socioeco-nomics, and lifestyle all determine how aging progresses foreach person. Indeed, one’s outward expression of age mayor may not reflect one’s chronologic age and there is a needto eliminate ageist stereotypes. See Figure 21-3.

Body CompositionBody composition changes with aging. Fat mass and visceral fat increase, whereas lean muscle mass decreases.Sarcopenia , the loss of muscle mass, strength, and function,

FIGURE 21-2 Percent of people ages 65 and older inpoverty by sex, race, and Hispanic origin. Note: Theterm non-Hispanic white alone is used to refer to people who reported being white and no other race and whoare not Hispanic. The term black alone is used to referto people who reported being black or African American and no other race, and the term Asian alone is used to refer to people who reported only Asian as

their race. Reference population: These data refer tothe resident population. (U.S. Census Bureau: Populationestimates and projections, 2000.)



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CHAPTER 21 | Nutrition in Aging 445

Theories on Aging

Category Theory Description

Predetermination: A built-inmechanism determines whenaging begins and time of death

Pacemaker theory “Biologic clock” is set at birth, runs for a specified time, winds down with aging, and ends at death.

Genetic theory Life span is determined by heredity.Rate of living

theory Each living creature has a finite amount of a “ vital substance,”

and, when it is exhausted, the result is aging and death.Oxygen metabolism

theory Animals with the highest metabolisms are likely to have the

shortest life spans.Immune system

theory Cells undergo a finite number of cell divisions that eventually

cause deregulation of immune function, excessiveinflammation, aging, and death.

Accumulated damage: Systemicbreakdown over time

Crosslink theory With time proteins, DNA and other structural molecules inthe body make inappropriate attachments, or crosslinks,to each other, leading to decreased mobility, elasticity, and

cell permeability. Wear-and-tear

theory Years of damage to cells, tissues, and organs eventually take

their toll, wearing them out and ultimately causing death.Free radical theory Accumulated, random damage caused by oxygen radicals

slowly cause cells, tissues, and organs to stop functioning.Somatic mutation

theory Genetic mutations caused by oxidizing radiations and other

factors accumulate with age, causing cells to deteriorateand malfunction.

DNA, Deoxyribonucleic acid.

TABLE 21-1

Providing Health Care for Older Americans Means Jobs

NEW DIRECTIONS

Registered dietitians (RDs) were identified by the Instituteof Medicine in 2000 as “the single group with the standard-

ized education and clinical training necessary to be directlyreimbursed through Medicare as providers of nutritiontherapy.” The projected growth for dietitians is 15% overall,but a remarkable 70% in home and residential care. The Centersfor Medicare and Medicaid Services is contracting with chroniccare improvement programs for individuals with nutrition-related conditions, including heart failure, diabetes, and chronicobstructive pulmonary disease. RDs have more opportunitiesbecause of the major expansion of medical nutrition therapyunder the Medicare Reform/Prescription Drug Law.

There are few college nutrition courses on healthyaging, but many on maternal and child health. Nutritiontextbooks have focused on geriatric illnesses and malnutrition(O’Neill et al., 2005). There is a need to better prepare

future RDs for these new opportunities. Nutrition studentsare encouraged to work with older adults because jobs aregrowing rapidly and financial incentives are strong.

Improving knowledge and attitudes about aging takesexposure to positive RD role models and older adults in a wide

variety of settings. There are opportunities in service projects,internship placements, and summer externships at communitydining centers, retirement centers, and assisted living andcontinuous-care facilities. Volunteering at food banks on days when older adults are scheduled to pick up groceries, teamingup with volunteers who deliver meals to the frail homebound,and participating in mealtime assistance for nursing homeresidents who cannot eat independently are good opportuni-ties. Student associations can sponsor activities that fosterinteractions across the spectrum of aging, from the well activeto the frail needy.

Full-time RDs have been shown to improve the quality ofnursing home care because their expertise is essential toprevent unintended weight loss, dehydration, and pressureulcers. Assisted living facilities and continuous-care commu-nities present job opportunities as they expand and serve more

at-risk persons. Positive experiences are sure to reduce ageiststereotypes, increase interest, and develop the skills needed toride America’s age wave.



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can be age-related, and can significantly affect an olderadult’s quality of life by decreasing mobility, increasing riskfor falls, and altering metabolic rates ( Janssen, 2009; Thomas,2010). Sarcopenia accelerates with a decrease in physicalactivity, but weight-bearing exercise can slow its pace. Although inactive persons have faster and greater losses ofmuscle mass, sarcopenia is also found in active older individuals, to a lesser degree. Currently no specified degree oflean body mass loss determines the diagnosis of sarcopenia. All losses are important because of the close connectionbetween muscle mass and strength. By the fourth decade oflife evidence of sarcopenia is detectable, and the processaccelerates after approximately age 75.

Sarcopenic obesity is the loss of lean muscle mass in olderpersons with excess adipose tissue. Together the excess weight and decreased muscle mass exponentially compoundto further decrease physical activity, which in turn acceler-ates sarcopenia. An extremely sedentary lifestyle in obesepersons is a major detractor from quality of life.

Sedentary lifestyle choices can lead to sedentary deathsyndrome (SeDS) , a phrase coined by The President’sCouncil on Physical Fitness. It describes the life-threateninghealth problems caused by a sedentary lifestyle. Sedentary

lifestyle can be defined as a level of inactivity below thethreshold of the beneficial health effects of regular physicalactivity or, more simply, burning fewer than 200 calories inphysical activity per day. The Surgeon General’ s Vision for a Healthy and Fit Nation 2010 emphasizes health consequencesof inactivity as greater risk for cardiovascular disease (CVD),hypertension, diabetes, dyslipidemia, obesity, overweight,and even death (U.S. Department of Health and HumanServices, 2010).

Few older adults achieve the minimum recommended 30or more minutes of moderate physical activity on 5 or moredays per week. Only 22% of adults older than age 65 reportengaging in regular leisure time physical activity ( Centersfor Disease Control and Prevention, 2006). Inactivity ismore common in older people than younger people; womenoften report no leisure-time activity. The American Collegeof Sports Medicine position emphasizes that all older adults

should engage in regular physical activity and avoid an inac-tive lifestyle ( American College of Sports Medicine, 2009). The Centers for Disease Control and Prevention (2010)quantifies the amount of exercise older adults need and theNational Institute on Aging (2010) has a guide for physicalactivity.

Taste and SmellSensory losses affect people to varying degrees, at varyingrates, and at different ages (Benelam, 2009; Schiffman,2009). Genetics, environment, and lifestyle are all part ofthe decline in sensory competence. Age-related alterations

to the sense of taste, smell, and touch can lead to poorappetite, inappropriate food choices, and lower nutrientintake. Although some dysgeusia (altered taste), loss oftaste, or hyposmia (decreased sense of smell) are attributableto aging, many changes are due to medications. Othercauses include conditions such as Bell’s palsy; head injury;diabetes; liver or kidney disease; hypertension; neurologicconditions, including Alzheimer’s disease and Parkinson’sdisease; and zinc or niacin deficiency. Untreated mouthsores, tooth decay, poor dental or nasal hygiene, and ciga-rette smoking also can decrease these senses.

Because taste and smell sensation thresholds are higher,older adults may be tempted to over-season foods, especiallyto add more salt, which may have a negative effect inmany older adults. Because taste and smell stimulate meta-bolic changes such as salivary, gastric acid, and pancreaticsecretions and increases in plasma levels of insulin, decreasedsensory stimulation may impair these metabolic processesas well.

Hearing and EyesightIn the United States 30% to 35% of adults ages 65 to 75and 50% of those older than age 75 have some degree ofhearing loss (National Institute on Deafness, 2006). Approx-imately one in four older adults who need a hearing aidactually use one. The most common type of hearing loss is

presbycusis . This loss is usually greater in the high-pitchedtonal range (e.g., telephone ring). The cumulative effect ofexposure to daily noises such as traffic, construction, loudmusic, noisy office, and machines causes a change to theinner ear complex. The change occurs slowly over time, andsufferers may not be aware of the loss.

Some vitamins may play a part in hearing loss. VitaminB12 , a nutrient often found to be deficient in the dietsof older adults, has been associated with increased ringing

FIGURE 21-3 Enjoying a meal together, these older peopleare interested in knowing how good nutrition can keep them

vigorous and healthy. (© 2011 Photos.com a division of Getty Images. All rights reserved.)



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increases the risk for aspiration pneumonia, an infectioncaused by food or fluids entering the lungs. Thickenedliquids and texture-modified foods can help people withdysphagia eat safely. The National Dysphagia Diet is in Appendix 35 and appropriate levels of texture modificationare also defined in Chapter 41.

Gastric changes can also occur. Decreased gastric mucosafunction leads to an inability to resist damage such as ulcers

cancer, and infections. Gastritis causes inflammation andpain, delayed gastric emptying, and discomfort. These alaffect the bioavailability of nutrients such as calcium andzinc and increase the risk of developing a chronic deficiencydisease such as osteoporosis.

Achlorhydria is the insufficient production of stomachacid. Approximately 30% of those older than age 50 havachlorhydria. Sufficient stomach acid and intrinsic factor arrequired for the absorption of vitamin B12 . Although substantial amounts are stored in the liver, B12 deficiency doeoccur. Symptoms, often misdiagnosed because they mimic Alzheimer’s disease or other chronic conditions, includeextreme fatigue, dementia, confusion, and tingling and

weakness in the arms and legs (see Chapters 3, 33 and 41) The incidence of diverticulosis increases with age. Halof the population older than age 60 develop it, but only 20%of them have clinical manifestations. The most commonproblems with diverticular disease are lower abdominal painand diarrhea (see Chapter 29).

Constipation is defined as having fewer bowel movements than usual, having difficulty or excessive straining astool, painful bowel movements, hard stool, or incompleteemptying of the bowel. Older adults are more likely than younger adults to become constipated. Primary causeinclude insufficient fluids, lack of physical activity, and lowintake of dietary fiber. Constipation is also caused by delayedtransit time in the gut and some medications like narcotics(See Chapter 9).

CardiovascularCVD includes heart disease and stroke. Although the effectof CVD are often measured by deaths in later life, it inot a disease of aging. This nutrition-related disease has itroots in unhealthy food choices made throughout one’lifetime (Neidert, 2005). CVD is the leading cause odeaths in both genders in the United States, in all raciaand ethnic groups. CVD age-related changes are extremely variable and are affected by environmental influences suchas smoking, exercise, and diet. Changes include decreasedarterial wall compliance, decreased maximum heart rate

decreased responsiveness to b -adrenergic stimuli, increasedleft ventricle muscle mass, and slowed ventricular relaxationOften the end result of hypertension and artery disease ischronic heart failure. A low sodium diet and fluid restrictionis integral to the treatment of this condition. These neces-sary diet restrictions in conjunction with other side effectof heart failure often lead to decreased nutrient consumption. See Chapter 34 for discussion of the multifacetedapproach required to manage CVD in the elderly.

in the ears, presbycusis, and reduced auditory brainstemresponse. Vitamin D may have an effect on hearing lossbecause of the role it plays in calcium metabolism, fluid andnerve transmission, and bone structure.

Vision loss is not a part of normal aging. However, every-one’s vision changes with age. For most the changes aresmall and correctable with glasses, improved lighting, orlarge print. Reading glasses often become necessary in the

fourth decade of life.

Immunocompetence As immunocompetence declines with age, immune responseis slower and less efficient. Changes occur at all levels ofthe immune system, from chemical alterations withinthe cells to differences in the kinds of proteins found on thecell surface and even to mutations to entire organs. Theprogressive decline in T-lymphocyte function and cell-mediated immunity contributes to the increased infectionand cancer rates seen in aging populations. The mechanismsof age-related changes in immune function are not fullyunderstood but likely depend on environmental factors

and lifestyle choices that affect overall immune function. Maintaining good nutritional status promotes good immunefunction.

OralDiet and nutrition can be compromised by poor oral health. Tooth loss, use of dentures, and xerostomia (dry mouth) canlead to difficulties in chewing and swallowing. Decreases intaste sensation and saliva production make eating less plea-surable and more difficult. Oral diseases and conditions arecommon among Americans who grew up without the benefitof community water fluoridation and other fluoride prod-ucts. Missing, loose, or rotten teeth or poor-fitting, painfuldentures make it difficult to eat some foods. People withthese mouth problems often prefer soft, easily chewed foodsand avoid some nutritionally dense options such as wholegrains, fresh fruits and vegetables, and meats.

The nutrition-related consequences of taking five ormore medications or over-the-counter drugs daily (poly-pharmacy ) are significant. More than 400 commonly usedmedications can cause dry mouth. See Chapter 9. Preparingfoods that are moisture-rich such as hearty soups and stews,adding sauces, and pureeing and chopping foods can allmake meals easier to eat. In addition, those with poor oralhealth may benefit from fortified foods with increased nutri-ent density. Although 30% of today’s adults 65 years andolder no longer have any natural teeth, tooth loss is no

longer part of normal aging.

GastrointestinalSome gastrointestinal (GI) changes may be age-related.Rather than ascribing any of these disorders to aging, thetrue clinical cause should be determined. GI changes cannegatively affect a person’s nutrient intake, starting in themouth. Dysphagia , a dysfunction in swallowing, is com-monly associated with neurologic diseases and senility. It



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clouding of the lens. The most common treatment is surgery;the clouded lens is removed and replaced with a permanentprosthetic lens. A diet high in antioxidants such as beta-carotene, selenium, resveratrol, and vitamins C and Emay delay cataract development. Studies show that a highsodium intake may increase risk of cataract development.Ultraviolet (UV) radiation exposure is directly related to 5%of worldwide cataracts. When the UV index is 3 and above,

protective sunglasses are recommended ( World HealthOrganization, 2009).

Diabetic retinopathy is a complication of diabetes (seeChapter 31). It occurs when blood vessels of the retina leakand produce spotty hemorrhages. Not all persons with dia-betes develop retinopathy; blood glucose control can helpprotect the retina from damage.

All forms of vision loss can negatively affect nutritionalstatus. Those with moderate-to-severe vision loss may havedifficulty shopping for, identifying, and preparing foods andself-feeding.

Depression

Psychological changes often manifest as depression and itsextent can vary widely from person to person. Among olderpersons depression is often caused by other conditions suchas heart disease, stroke, diabetes, cancer, grief, or stress.Depression in older people is frequently undiagnosed ormisdiagnosed because symptoms are confused with othermedical illnesses. Untreated depression can have seriousside effects for older adults. It diminishes the pleasures ofliving, including eating; it can exacerbate other medicalconditions; and it can compromise immune function. It isassociated with decreased appetite, weight loss, and fatigue.Nutritional care plays an important role in addressingthis condition (see Chapter 42). Providing nutrient- andcalorie-dense foods, additional beverages, texture-modifiedfoods, and favorite foods at times when people are mostlikely to eat the greatest quantity can be very effective.In that comorbidities lead to polypharmacy and concernregarding drug-drug interactions, providers may choose toomit antidepressants, which leaves the depression untreated.

Pressure UlcersPressure ulcers , formerly called bedsores or decubitus ulcers, develop from continuous pressure that impedes capillaryblood flow to skin and underlying tissue. Several factorscontribute to the formation of pressure ulcers, but impairedmobility and urinary incontinence are key. Older adults with neurologic problems, those heavily sedated, and those

with dementia are often unable to shift positions to alleviatepressure. Paralysis, incontinence, sensory losses, and rigiditycan all contribute to the problem. Notably malnutrition(inadequate protein) and undernutrition (inadequate energyintake) set the stage for its development and can delay wound healing. The escalating chronic nature of pressureulcers in bed-ridden or sedentary elderly requires vigilantattention to nutrition.

Several classification systems exist to describe pressureulcers. The four stages of pressure ulcers, based on the

Renal

Age-related changes in renal function vary tremendously.Some older adults experience little change, whereas otherscan have devastating, life-threatening change. On averageglomerular filtration rate, measured in creatinine clearancerates, declines by approximately 8 to 10 mL/min/1.73m2 / decade after age 30 to 35. The resulting increase in serum

creatinine concentrations should be considered when deter-mining medication dosages. The progressive decline inrenal function can lead to an inability to excrete concen-trated or dilute urine, a delayed response to sodium depriva-tion or a sodium load, and delayed response to an acid load.Renal function is also affected by dehydration, diuretic use,and medications, especially antibiotics.

Neurologic There can be significant age-related declines in neurologicprocesses. Cognition, steadiness, reactions, coordination,gait, sensations, and daily living tasks can decline as muchas 90% or as little as 10%. On average, the brain loses 5%

to 10% of its weight between the ages of 20 and 90, butmost if not all neurons are functional until death unless aspecific pathologic condition is present.

It is important to make the distinction between normal,age-related decline and impairment from conditions such asdementia, a disease process. Memory difficulties do not nec-essarily indicate dementia, Alzheimer’s disease, Parkinson’sdisease, or any mental disorder (see Chapter 41). Manychanges in memory can be attributed to environmentalfactors, including stress, chemical exposure, and poor dietrather than to physiologic processes. However, even mildcognitive impairment that affects approximately 20% ofthose older than age 70 may affect eating, chewing, andswallowing, thus increasing the risk of malnutrition.

COMMON HEALTH PROBLEMS

Eye DiseaseAge-related macular degeneration (AMD) is the leadingcause of blindness in people older than age 65 in the UnitedStates; it may also be linked to an increased risk for stroke( Wong, 2006). AMD occurs when the macula, the centerpart of the retina, degrades. The result is central vision loss. The macular pigment is composed of two chemicals, luteinand zeaxanthin. A diet rich in fruits and vegetables may helpdelay or prevent the development of AMD. Zinc has also

been shown to decrease the risk of developing AMD. Finally,correcting obesity and smoking are modifiable factors thatcan reduce progression of AMD (Clemons, 2006).

Glaucoma is damage to the optic nerve resulting fromhigh pressure in the eye. It is the second most commoncause of vision loss in the United States and affects approxi-mately 3 million Americans. Hypertension, diabetes, andCVD all increase the risk of glaucoma.

A cataract is a clouding of the lens of the eye. Approxi-mately half of Americans 65 and older have some degree of



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(toileting, bathing, eating, dressing) and instrumental activities of daily living (IADLs) such as managing money, shopping, telephone use, travel in community, housekeepingpreparing meals, taking medications correctly, and otheindividual self-performance skills needed in everyday lifeare used to monitor physical function.

Many nutrition-related diseases affect functional status inolder individuals. Inadequate nutrient intake may hasten

loss of muscle mass and strength, which can have a negativeffect on performing ADLs. Among the older adults whohave one or more nutrition-related chronic diseasesimpaired physical function may cause greater disability, withincreased morbidity, nursing home admissions or death.

Weight MaintenanceObesity

The prevalence of obesity in all ages has increased durinthe past 25 years in the United States; older adults areno exception. Obesity rates are greater among those age65 to 74 than among those age 75 and older. Obesity i

associated with increased mortality and contributes tomany chronic diseases: type 2 diabetes, heart disease, hypertension, arthritis, dyslipidemia, and cancer. Obesity causea progressive decline in physical function, which may leadto increased frailty. Overweight and obesity can lead to decline in IADLs.

Current data demonstrate that weight-loss therapyimproves physical function, quality of life, and reduces themedical complications associated with obesity in oldepersons ( Villareal, 2005). Accordingly, weight loss therapiethat maintain muscle and bone mass are recommended foobese older adults. Lifestyle changes that include dietphysical activity, and behavior modification techniqueare the most effective. The goals of weight loss andmanagement for adults are the same for the general population, and should include prevention of further weight gainor reduction of body weight, and maintenance of long-term weight loss.

Weight loss of 10% of total body weight over 6 monthshould be the initial goal. After that, strategies for maintenance should be implemented. Dietary changes include anenergy deficit of 500-1000 kcal/day. Usual caloric goalrange from 1200-1800 kcal/day but should not be less than800 kcal/day. It is critical for the older adult on a calorierestricted diet to meet nutrient requirements. This maynecessitate the use of a multivitamin or mineral supplemenas well as nutrition education.

Underweight and Malnutrition

The actual prevalence of underweight among older adultis quite low; older women older than age 65 are three timeas likely as their male counterparts to be underweigh(Federal Interagency Forum, 2008). However, many olderadults are at risk for undernutrition and malnutrition Among those hospitalized, 40% to 60% are malnourishedor at risk for malnutrition, 40% to 85% of nursing homeresidents have malnutrition, and 20% to 60% of home care

depth of the sore and level of tissue involvement, aredescribed in Table 21-2. Thomas (2009) suggests that woundnutrition equals whole-body nutrition, and coordinatedefforts of a multidisciplinary treatment team are important.Nutrition recommendations for the treatment of pressureulcers are as follows (Doley, 2010; Thomas, 2009):

• Optimize protein intake with a goal of 1.25 to 2 g/kg/

day.• Meet calorie requirements at 30-40 kcal/kg/day.• Assess the effect of medications on wound healing and

supplement if indicated.• Replace micronutrients if depleted—routine supple-

mentation is not warranted.

Frailty and Failure to Thrive The four syndromes known to be predictive of adverseoutcomes in older adults that are prevalent in patients withfrailty or “geriatric failure to thrive” include impaired physi-cal functioning, malnutrition, depression, and cognitive

impairment. Symptoms include weight loss, decreased appe-tite, poor nutrition, dehydration, inactivity, and impairedimmune function. Interventions should be directed ateasily remediable contributors in the hope of improvingoverall functional status. Nutrition interventions, especiallythose rectifying protein-energy malnutrition (PEM), areessential.

QUALITY OF LIFE

Quality of life is a general sense of happiness and satisfaction with one’s life and environment. Health-related quality oflife is the personal sense of physical and mental health andthe ability to react to factors in the physical and social envi-ronments. To assess health-related quality of life, commonmeasures and scales, either general or disease-specific, canbe used. Because older age is often associated with healthproblems and decrease in functionality, quality-of-life issuesbecome relevant.

Food and nutrition contribute to one’s physiologic, psy-chological, and social quality of life. A measure of nutrition-related quality of life has been proposed to documentquality-of-life outcomes for individuals receiving medicalnutrition therapy. Effective strategies to improve eating andthereby improve nursing home residents’ quality of life are well established but could be more widely implemented(Kamp et al., 2010; Neidert, 2005).

Functionality Functionality and functional status are terms used to describephysical abilities and limitations in, for example, ambula-tion. Functionality , the ability to perform self-care,self-maintenance, and physical activities, correlates withindependence and quality of life. Disability rates amongolder adults are declining, but the actual number considereddisabled is increasing as the size of the aging populationgrows. Limitations in activities of daily living (ADLs)



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Pressure Ulcer Stages and Nutritional Recommendations

Suspected Deep Tissue InjuryPurple or maroon localized area of discolored intact skin or

blood-filled blister caused by damage of underlying softtissue from pressure or shear. The area may be preceded

by tissue that is painful, firm, mushy, boggy, warmer, orcooler as compared with adjacent tissue.Deep tissue injury may be difficult to detect in individuals

with dark skin tones. Evolution may include a thinblister over a dark wound bed. The wound may furtherevolve and become covered by thin eschar. Evolutionmay be rapid, exposing additional layers of tissue even with optimal treatment.

Energy: 30 calories/kg BWNormal protein requirements in healthy adults are

approximately 0.8 g/kg of body weight and 1 g/kg BWin the elderly.

Stage IIntact skin with nonblanchable redness of a localized area,

usually over a bony prominence. Darkly pigmented skinmay not have visible blanching; its color may differ fromthe surrounding area.

The area may be painful, firm, soft, warmer, or cooler ascompared with adjacent tissue. Stage I may be difficultto detect in individuals with dark skin tones. Mayindicate “at-risk” persons (a heralding sign of risk).

Energy: 30 to 35 calories/kg BWProtein: 1.25 to 1.5 grams/kg BWFluid: 30 to 33 cc/kg BW; possibly less fluid for patients

with severe renal disease or congestive heart failure.

Stage IIPartial thickness loss of dermis presenting as a shallow

open ulcer with a red pink wound bed without slough. May also present as an intact or open or rupturedserum-filled blister.

Presents as a shiny or dry, shallow ulcer without slough orbruising. This stage should not be used to describe skintears, tape burns, perineal dermatitis, maceration,or excoriation.

Bruising indicates suspected deep tissue injury.

Energy: 30 to 35 calories/kg BWProtein: 1.25 to 1.5 grams/kg BWFluid: 30 to 33 cc/kg BW; possibly less fluid for patients

with severe renal disease or congestive heart failure.

Stage IIIFull-thickness tissue loss. Subcutaneous fat may be visible

but bone, tendon, or muscle are not exposed. Sloughmay be present but does not obscure the depth of tissueloss. May include undermining and tunneling.

The depth of a stage III pressure ulcer varies by anatomiclocation. The bridge of the nose, ear, occiput, andmalleolus do not have subcutaneous tissue, and stageIII ulcers can be shallow. In contrast, areas of significantadiposity can develop extremely deep stage III pressureulcers. Bone and tendon are not visible or directlypalpable.

Energy: 35 to 40 calories/kg BWProtein: 1.5 to 1.75 g/kg BW (Note: Assessment of protein

needs should be determined after an assessment of visceral protein status has been completed, keeping inmind that stressed patients with protein depletionusually cannot metabolize more than 2 g/kg BWper day.)

Fluid: 30 to 33 cc/kg BW; possibly less fluid for patients with severe renal disease or congestive heart failure. Additional fluids are needed for patients with draining wounds, fever, and other fluid losses. Patients onair-fluidized beds may become dehydrated because ofincreased evaporative water loss; extra 10 to 15 mL/kg

BW may be needed. A multivitamin with 15 mg of zinc will be adequate for

most patients.

TABLE 21-2



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Pressure Ulcer Stages and Nutritional Recommendations—cont’d

TABLE 21-2

Stage IVFull-thickness tissue loss with exposed bone, tendon, or

muscle. Slough or eschar may be present on some partsof the wound bed. Often include undermining and

tunneling. The depth of a stage IV pressure ulcer varies by anatomiclocation. The bridge of the nose, ear, occiput, andmalleolus do not have subcutaneous tissue, and theseulcers can be shallow. Stage IV ulcers can extend intomuscle and supporting structures (e.g., fascia, tendon,or joint capsule), making osteomyelitis possible. Exposedbone or tendon is visible or directly palpable.

Energy: 35 to 40 calories/kg BWProtein: 1.75 to 2 g/kg BW (Note: Assessment of protein

needs should be determined after an assessment of visceral protein status has been completed, keeping in

mind that stressed patients with protein depletionusually cannot metabolize more than 2 g/kg of body weight each day.)

Fluid: 30 to 33 cc/kg BW; possibly less fluid for patients with severe renal disease or congestive heart failure. Additional fluids are needed for patients with draining wounds, fever, and other fluid losses. Patients onair-fluidized beds may become dehydrated because ofincreased evaporative water loss; extra 10 to 15 mL/kgbody weight may be needed.

A multivitamin with 15 mg of zinc/day may be adequatefor most patients; some may require more zinc.

UnstageableFull-thickness tissue loss in which the base of the ulcer is

covered by slough (yellow, tan, gray, green, or brown) oreschar (tan, brown, or black) in the wound bed. Untilenough slough or eschar is removed to expose the baseof the wound, the true depth, and therefore stage,cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heelsserves as “the body’s natural (biologic) cover” and shouldnot be removed.

Often treated as a stage IV.

BW, Body weight.

Sources: National Pressure Ulcer Advisory Panel, 2007; reprinted with permission. American Dietetic Association. Consultant Dietitians in Health CareFacilities. Pocket Resource for Nutrition Assessment. 2005 Revision; 69-73.

patients are malnourished. Many community-residing olderpersons consume fewer than 1000 kcal/day, an amount notadequate to maintain good nutrition. Some causes of under-nutrition include medications, depression, decreased senseof taste or smell, poor oral health, chronic diseases, dyspha-gia, and other physical problems that make eating difficult.Social causes may include living alone, inadequate income,lack of transportation, and limitations in shopping for andpreparing food.

Health care professionals frequently overlook PEM. Thephysiologic changes of aging, as well as changes in livingconditions and income, all contribute to the problem.

Symptoms of PEM are often attributed to other conditions,leading to misdiagnosis. Some common symptoms are con-fusion, fatigue, and weakness. Older adults with low incomes, who have difficulty chewing and swallowing meat, whosmoke, or engage in little or no physical activity are atincreased risk of developing PEM.

Strategies to decrease PEM include increased caloric andprotein intake. In a clinical setting nutritional oral supple-ments and enteral feedings may be used. Frailty is often

related to micronutrient deficiencies, especially in women( Michelon, 2006). Older malnourished adults are at risk orefeeding syndrome when they begin to receive nutritionsupport, and this should be assessed (see Chapter 14).

In a community setting older adults should be encouraged to eat energy-dense and high-protein foods. Dierestrictions should be liberalized to offer more choices Adding gravies and creams can increase calories and softenfoods for easier chewing ( Joshipura, 2009). Federal food andnutrition services are also available for older adults.

NUTRITION SCREENINGAND ASSESSMENT

The Mini Nutritional Assessment (MNA) (Bauer, 2008includes two sections: screening and assessment. The ShorForm is the most widely used screening method to identifymalnutrition in noninstitutionalized older adults. It includesix questions and a body mass index (BMI) evaluation, or calf circumference, if a BMI is not possible. The MNA



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NUTRITION NEEDS

Many older adults have special nutrient requirementsbecause aging affects absorption, use, and excretion ofnutrients (Kuczmarski and Weddle, 2005). The dietaryreference intakes (DRIs) separate the cohort of peopleage 50 and older into two groups, ages 50-70 and 71 andolder. Based on the Healthy Eating Index, older Americans

need to increase their intakes of whole grains, dark greenand orange vegetables, legumes, and milk; choose morenutrient-dense forms of foods, that is, foods low in solid fatsand free of added sugars; and lower their intake of sodiumand saturated fat ( Juan, 2008). Other studies show that olderpersons have low intakes of calories, total fat, fiber, calcium,magnesium, zinc, copper, folate, and vitamins B12 , C, E, andD (Box 21-1).

The Mifflin-St. Jeor energy equation can be usedto assess calorie needs in older adults (see Chapter 2). DRItables ( Table 21-3; see inside cover) can also be used.Here, DRIs for energy suggest 3067 kcal/day for men and2403/day for women 18 years; subtract 10 kcal/day for men

and 7 kcal/day for women for each year of age older than19 years. The DRIs are not specific for protein in older adults.

After age 65, the minimum protein requirement is 1 gprotein/kg of body weight (Chernoff, 2004). New evidence

Short Form has been validated (Kaiser, 2009). For a com-plete nutrition assessment, the full MNA is used. It is themost commonly used assessment tool in long-term care (seeFigs 4-4 and 4-5.).

Some assessment measures are not necessarily accurateor feasible to use with older adults ( Morley, 2009). Physicaland metabolic changes of aging can yield inaccurateresults. An illustration of this is anthropometric measure-

ments such as height and weight, and BMI. With aging,fat mass increases and height decreases as a result of vertebral compression ( Villareal, 2005). An accurate heightmeasure may be difficult in those unable to stand upstraight, the bed bound, those with spinal deformationssuch as a dowager’s hump, and those with osteoporosis. Measuring arm span or knee height may give more accuratemeasurements. See Appendix 20. BMIs based on question-able heights are inaccurate. Clinical judgment is neededfor accuracy.

Body composition measures may also be ineffective.Skin-fold thickness and mid-arm circumference used todetect changes in body fat are limited in their ability to

distinguish between changes in fat and muscle mass, becauseof decreased elasticity and increased compressibility of olderskin. Mid-arm muscle circumference measures may be moreaccurate and sensitive to weight change than overall bodycomposition measurements.

Dietary Guidelines for Americans

BOX 21-1

KEY RECOMMENDATIONS FOR OLDER ADULTS • Maintain calorie balance over the lifetime to achieveand sustain a healthy weight. Healthy eating patternslimit intake of sodium, solid fats, added sugars, andrefined grains. Increased physical activity and reducedtime spent in sedentary behaviors are also desired.

• Focus on consuming nutrient-dense foods andbeverages. A healthy eating pattern emphasizes nutrient-dense foods and beverages. Select fat-free or low-fat milkand milk products, seafood, lean meats and poultry, eggs,beans and peas, and nuts and seeds. Choose vegetables,fruits, whole grains, and milk and milk products for morepotassium, dietary fiber, calcium, and vitamin D as

nutrients of concern. Eat a variety of vegetables,especially dark-green and red and orange vegetables,beans and peas. Consume at least half of all grains as whole grains.

• Nutrient needs should be met primarily throughconsuming foods. When needed, fortified foods anddietary supplements may be useful in providing one ormore nutrients that otherwise might be consumed in lessthan recommended amounts. Consume foods fortified with vitamin B12, such as fortified cereals, or dietary

supplements. Two eating patterns that are beneficial are Vegetarian adaptations and the DASH (Dietary Approaches to Stop Hypertension) Eating Plan.

• A healthy eating pattern should prevent foodborneillness. Four basic food safety principles (Clean, Separate,Cook, and Chill) work together to reduce the risk offoodborne illnesses. In addition, some foods (such asmilks, cheeses, and juices that have not been pasteurized,and undercooked animal foods) pose high risk forfoodborne illness and should be avoided.

• Use alcohol in moderation. If alcohol is consumed, itshould be consumed in moderation—up to one drink perday for women and two drinks per day formen—and only by adults of legal drinking age.

• Individuals should meet the following recommendationsas part of a healthy eating pattern while staying withintheir calorie needs.

• Information on the type and strength of evidencesupporting the Dietary Guidelines recommendations canbe found at http://www.nutritionevidencelibrary.gov.

Source: U.S. Department of Health and Human Services, U.S. Departmentof Agriculture: Dietary Guidelines for Americans, 2010, ed 7, Washington,DC, 2010, U.S. Government Printing Office.



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supports 1 g/kg, even up to 1.2 gm/kg. In those indivi-duals with impaired renal function or long-standing diabe-tes, .8g/kg to 1.0 g/kg may be more appropriate. Evenprotein distribution throughout the day with no singleserving exceeding 30 g (Symons et al., 2009) should be agoal.

MEDICARE BENEFITS The Social Security Act of 1965 created the Medicareprogram to cover most of the health care costs of those 65and older and persons with disabilities. However, this feder-ally funded health insurance program does not cover theentire cost of long-term care (LTC). A portion of payrolltaxes and monthly premiums deducted from Social Securitypayments finance Medicare.

Medicare benefits are provided in four parts. Part A covers inpatient hospital care, some skilled nursing care,hospice care, and some home health care costs for limitedperiods of time. It is premium-free for most citizens. Part B has a monthly premium that helps pay for doctors, outpa-

tient hospital care, and some other care not covered by Part A (physical and occupational therapy, for example). Part C allows private insurers, including health maintenance orga-nizations (HMOs) and referred provider organizations(PPOs), to offer health insurance plans to Medicare benefi-ciaries. These must provide the same benefits the original Medicare plan provides under Parts A and B. Part C HMOsand PPOs may also offer additional benefits, such as dentaland vision care. Part D provides prescription drug benefitsthrough private insurance companies.

The 2010 health care reform legislation changed Medi-care to include an annual wellness visit and a personalizedprevention assessment and plan with no copayment ordeductible. Prevention services include referrals to educa-tion and preventive counseling or community-based interventions to address risk factors. The new law mandates thecreation of the Independence at Home DemonstrationProject, a demonstration program to begin by 2012. It willenroll chronically ill Medicare beneficiaries to test a paymentincentive and service delivery system that uses physician-and nurse practitioner–directed home-based primary careteams aimed at reducing costs and improving health out-comes. The 2010 law expands medical nutrition therapyreimbursement for registered dietitians to cover therapyconsidered reasonable and necessary for the prevention ofan illness or disability.

The Home and Community-Based Services (HCBS)

Waivers, Section 1915 (c), provide service to nursing home– appropriate older adults to help prevent or decrease nursinghome or LTC institutionalization. States may offer anunlimited variety of services under this waiver. These waiverprograms may provide both traditional medical services(dental, skilled nursing) and nonmedical services (mealdelivery, case management, environmental modifications).States have the discretion to choose the number of olderpersons served. Forty-eight states (Michigan and Utah arethe exceptions) and the District of Columbia offer services

through HCBS waivers; currently there are approximately287 active programs.

NUTRITION SUPPORT SERVICES

U.S. Department of Health andHuman Services Older Americans

Act Nutrition Program (OAA) The OAA Nutrition Program is the largest, most visiblefederally funded community-based nutrition program foolder persons. Primarily a state-run program, it has fewfederal regulations and considerable variation in stateto-state policies and procedures. This nutrition programprovides congregate and home-delivered meals (usually 5days/week), nutrition screening, education, and counselingas well as an array of other supportive and health services Although frequently called meals on wheels, that term accurately refers only to the home-delivered meals. Participantare poorer, older, sicker, frailer, more likely to live alone, bemembers of minority groups, and live in rural areas (USAoA

2008). The OAA Nutrition Program, available to personage 60 and older, successfully targets those in greatest economic and social need, with particular attention to lowincome minorities and rural individuals. More than half othe OAA annual budget supports the Nutrition Program which provides approximately 240 million congregate andhome-delivered meals to 2.6 million older adults annuallyHome-delivered meals have grown to more than 60% of almeals served; almost half of the programs have waiting lists To receive home-delivered meals, an individual must bassessed to be homebound or otherwise isolated. Homedelivered meal recipients are especially frail; half are at highnutrition risk or are malnourished and approximately onethird qualify as nursing-home appropriate.

At congregate sites, the Nutrition Program provideaccess and linkages to other community-based services. It ithe primary source of food and nutrients for many programparticipants and presents opportunities for active sociaengagement and meaningful volunteer roles. Participanthave higher daily intakes of key nutrients than similar non-participants. The meals are nutritionally dense per caloriand each meal supplies more than 33% of the recommendeddietary allowances (an OAA requirement) and provides 40%to 50% of daily intakes of most nutrients (USAoA, 2008)Otherwise, inadequate nutrient intake affects approximatel37% to 40% of community-dwelling individuals 65 years oage and older (Federal Interagency Forum, 2008).

The OAA Nutrition Program has neither received theresearch or evaluation attention that a program its sizedeserves, nor the growth in federal funding to keeppace with inflation and the growing numbers of older adult( Wellman, 2010). The program reaches fewer than 5% oolder Americans, and those served average fewer than thremeals per week. The OAA Nutrition Program is closelylinked to home- and community-based services (HCBSthrough cross-referrals through the Aging Network. Becauseolder adults are being discharged earlier from hospitals and



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N u t r i e n t N e e d s C h a n g

e W i t h A g i n g

N u t r i e n t

C h a n g e s w i t h A g i n g

P

r a c t i c a l S o l u t i o n s

E n e r g y

B a s a l m e t a b o l i c r a t e d e c r e a s e s w i t h a g e b e c a u s e o f c h a n g e s

i n b o d y c o m p o s i t i o n .

E n e r g y n e e d s d e c r e a s e ∼ 3 % p e r d e c a d e i n a d u l t s .

E n c o u r a g e n u t r i e n t - d e n s e f o o d s i n a m o u n t s a p p r o p r i a t e f o r

c a l o r i c n e e d s .

P r o t e i n 0 . 8 g / k g

m i n i m u m

M i n i m a l c h a n g e w i t h a g e b u t r e s e a r c h i s n o t c o n c l u s i v e .

R e q u i r e m e n t s v a r y w i t h c h r o

n i c d i s e a s e , d e c r e a s e d

a b s o r p t i o n , a n d s y n t h e s i s .

P r o t e i n i n t a k e s h o u l d n o t b e r o u t i n e l y i n c r e a s e d ; e x c e s s p r o t e i n

c o u l d u n n e c e s s a r i l y s t r e s s a g i n g k i d n e y

s .

C a r b o h y d r a t e s 4 5 % - 6 5 %

o f t o t a l c a l o r i e s

M e n 3 0 g fi b e r

W o m e n 2 1 g fi b e r

C o n s t i p a t i o n m a y b e a s e r i o u s c o n c e r n f o r m a n y .

E m p h a s i z e c o m p l e x c a r b o h y d r a t e s : l e g u m

e s , v e g e t a b l e s , w h o l e

g r a i n s , f r u i t s t o p r o v i d e fi b e r , e s s e n t i a l

v i t a m i n s , m i n e r a l s .

I n c r e a s e d i e t a r y fi b e r t o i m p r o v e l a x a t i o n e s p e c i a l l y i n

o l d e r a d u l t s .

L i p i d s 2 0 % - 3 5 % t o t a l

c a l o r i e s

H e a r t d i s e a s e i s a c o m m o n d i a g

n o s i s .

O

v e r l y s e v e r e r e s t r i c t i o n o f d i e t a r y f a t s a l t e r s t a s t e , t e x t u r e , a n d

e n j o y m e n t o f f o o d ; c a n n e g a t i v e l y a f f e c t o v e r a l l d i e t , w e i g h t ,

a n d q u a l i t y o f l i f e .

E m p h a s i z e h e a l t h y f a t s r a t h e r r e s t r i c t i n g

f a t .

V i t a m i n s a n d M i n e r a l s

U n d e r s t a n d i n g v i t a m i n a n d m i n e r a l r e q u i r e m e n t s ,

a b s o r p t i o n , u s e , a n d e x c r e t i o n w i t h a g i n g h a s i n c r e a s e d

b u t m u c h r e m a i n s u n k n o w n .

E n c o u r a g e n u t r i e n t - d e n s e f o o d s i n a m o u n t s a p p r o p r i a t e f o r

c a l o r i c n e e d s .

O

x i d a t i v e a n d i n fl a m m a t o r y p r o c e s s e s a f f e c t i n g a g i n g

r e i n f o r c e t h e c e n t r a l r o l e o f m i c r o n u t r i e n t s , e s p e c i a l l y

a n t i o x i d a n t s .

V i t a m i n B 1 2 2 . 4 m g

R i s k o f d e fi c i e n c y i n c r e a s e s b e c

a u s e o f l o w i n t a k e s o f

v i t a m i n B 1 2 , a n d d e c l i n e i n g a s t r i c a c i d , w h i c h f a c i l i t a t e s

B 1 2 a b s o r p t i o n .

T

h o s e 5 0 a n d o l d e r s h o u l d e a t f o o d s f o r t

i fi e d w i t h t h e

c r y s t a l l i n e f o r m o f v i t a m i n B 1 2 s u c h a s

i n f o r t i fi e d c e r e a l s o r

s u p p l e m e n t s .

T A B L E

2 1 - 3



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N u t r i e n t

C h a n g e s w i t h A g i n g

P

r a c t i c a l S o l u t i o n s

V i t a m i n D

8 0 0 - 1 , 0 0 0 I U

R i s k o f d e fi c i e n c y i n c r e a s e s a s s y n t h e s i s i s l e s s e f fi c i e n t ; s k i n

r e s p o n s i v e n e s s a s w e l l a s e x p o s u r e t o s u n l i g h t d e c l i n e ;

k i d n e y s a r e l e s s a b l e t o c o n v e r t D 3 t o a c t i v e h o r m o n e

f o r m . A s m a n y a s 3 0 % - 4 0 %

o f t h o s e w i t h h i p f r a c t u r e s

a r e v i t a m i n D i n s u f fi c i e n t .

S u p p l e m e n t a t i o n m a y b e n e c e s s a r y . T h i s

s u p p l e m e n t i s

i n e x p e n s i v e , w h e r e a s t e s t i n g f o r v i t a m i n D d e fi c i e n c y i s

c o s t l y a n d t h e l a b o r a t o r y m e t h o d s a r e n o t c o m p l e t e l y

a s s u r e d a t t h i s p o i n t . A s u p p l e m e n t i s i n d i c a t e d i n v i r t u a l l y

a l l i n s t i t u t i o n a l i z e d o l d e r a d u l t s .

F o l a t e 4 0 0 μ g

M a y l o w e r h o m o c y s t e i n e l e v e l s ; p o s s i b l e r i s k m a r k e r f o r

a t h e r o t h r o m b o s i s , A l z h e i m e r

d i s e a s e , a n d P a r k i n s o n

d i s e a s e .

F o r t i fi c a t i o n o f g r a i n p r o d u c t s h a s i m p r o v e d f o l a t e s t a t u s .

W h e n s u p p l e m e n t i n g w i t h f o l a t e , m u s t m o n i t o r B 1 2 l e v e l s .

C a l c i u m 1 2 0 0 m g

D i e t a r y r e q u i r e m e n t m a y i n c r e a s e b e c a u s e o f d e c r e a s e d

a b s o r p t i o n ; o n l y 4 % o f w o m e n a n d 1 0 % o f m e n a g e 6 0

a n d o l d e r m e e t d a i l y r e c o m m

e n d a t i o n .

R e c o m m e n d n a t u r a l l y o c c u r r i n g a n d f o r t i fi e d f o o d s .

S u p p l e m e n t a t i o n m a y b e n e c e s s a r y .

P o t a s s i u m 4 7 0 0 m g

P o t a s s i u m - r i c h d i e t c a n b l u n t t h e e f f e c t o f s o d i u m o n

b l o o d p r e s s u r e .

R e c o m m e n d m e e t i n g p o t a s s i u m r e c o m m e n d a t i o n w i t h f o o d ,

e s p e c i a l l y f r u i t s a n d v e g e t a b l e s .

S o d i u m 1 5 0 0 m g

R i s k o f h y p e r n a t r e m i a c a u s e d b

y d i e t a r y e x c e s s a n d

d e h y d r a t i o n .

R i s k o f h y p o n a t r e m i a c a u s e d b y fl u i d r e t e n t i o n .

R e c o m m e n d c o n s u m i n g 1 5 0 0 t o n o m o r e t h a n 2 3 0 0 m g / d .

Z i n c

M e n 1 1 m g

W o m e n 8 m g

L o w i n t a k e a s s o c i a t e d w i t h i m p

a i r e d i m m u n e f u n c t i o n ,

a n o r e x i a , l o s s o f s e n s e o f t a s t e , d e l a y e d w o u n d h e a l i n g ,

a n d p r e s s u r e u l c e r d e v e l o p m e n t .

E n c o u r a g e f o o d s o u r c e s : l e a n m e a t s , o y s t

e r s , d a i r y p r o d u c t s ,

b e a n s , p e a n u t s , t r e e n u t s a n d s e e d s .

W a t e r

H y d r a t i o n s t a t u s c a n e a s i l y b e p r o b l e m a t i c . D e h y d r a t i o n

c a u s e s d e c r e a s e d fl u i d i n t a k e , d e c r e a s e d k i d n e y f u n c t i o n ,

i n c r e a s e d l o s s e s c a u s e d b y i n c r e a s e d u r i n e o u t p u t f r o m

m e d i c a t i o n s ( l a x a t i v e s , d i u r e t i c s ) .

S y m p t o m s : e l e c t r o l y t e i m b a l a n c e , a l t e r e d d r u g e f f e c t s ,

h e a d a c h e , c o n s t i p a t i o n , b l o o d p r e s s u r e c h a n g e , d i z z i n e s s ,

c o n f u s i o n , d r y m o u t h a n d n o

s e .

E n c o u r a g e fl u i d i n t a k e o f a t l e a s t 1 5 0 0 m

L / d a y o r 1 m L p e r

c a l o r i e c o n s u m e d .

R i s k i n c r e a s e s b e c a u s e o f i m p a i r e d s e n s e

o f t h i r s t , f e a r o f

i n c o n t i n e n c e , a n d d e p e n d e n c e o n o t h e r s t o g e t b e v e r a g e s .

D e h y d r a t i o n i s o f t e n u n r e c o g n i z e d ; i t c a n p r e s e n t a s f a l l s ,

c o n f u s i o n , c h a n g e i n l e v e l o f c o n s c i o u s n e s s , w e a k n e s s o r

c h a n g e i n f u n c t i o n a l s t a t u s , o r f a t i g u e .



15/18


and disability services, health and human service, markets,public health, state units on aging, or state food and nutri-tion services. SFMNP provides coupons to low-incomeolder individuals to purchase fresh, unprepared foods atfarmers’ markets, roadside stands, and community-supportedagriculture programs. It provides eligible older adults withlocal, seasonal access to fresh fruits, vegetables, and herbs.

Medicaid and Nutrition Services The Social Security Act suggests seven core HCBS waiverprogram services: case management, homemaker services,home health aide services, personal care services, adult dayhealth, rehabilitation, and respite care. Note that nutritionservice is not a core Medicaid service. Older persons whoare eligible for nursing home placement are not usually ableto shop for food, store food safely, or plan and preparenutritionally appropriate meals. Thus a strong argument canbe made to fund all or some meals and nutrition servicesbased on health and nutrition risk criteria. Yet only 38 statesinclude meals or nutrition services among the specified ben-efits available through Medicaid waivers. Approved nutri-

tion services include home-delivered meals, nutrition riskreduction counseling, and nutritional supplements asappropriate.

ASSISTED LIVING ANDSKILLED CARE FACILITIES

Several million older adults live in senior housing of varioustypes, (assisted living or residential care communities, skilledsenior apartments, continuing care communities, indepen-dent retirement living). Some sites have supportive servicesavailable to their residents, including meals and servicesthrough the older adult nutrition program.

Assisted living communities (ALCs) generally serve thefastest growing population segment—those ages 85 andolder. The estimated 33,000 licensed ALCs are home toapproximately 1 million persons. They combine housingand personalized supportive and health care for those whoneed help with ADLs. Often residents move to ALCs whenthey can no longer safely live alone, have some cognitiveimpairment, and require supervision and “cueing” abouttheir daily routine. ALCs usually involve the resident’sfamily, neighbors, and friends. Care is provided in ways thatpromote maximum independence and dignity. Assistedliving residences cost less than nursing home care. Residentsare encouraged to maintain active social lives with planned

activities, exercise classes, religious and social functions, andfield trips directed by the facilities. These facilities are notrequired to provide therapeutic diets and can be a problemfor patients with special requirements, such as those withheart failure.

Comprehensive state regulations for food and nutritionservices in ALCs are rare, but there is early consensus of what should be regulated (Chao, 2009). Emphasizing thatfood and nutrition matter at every age, it is essential that

nursing homes, many require a care plan that includeshome-delivered meals and other nutrition services (e.g.,nutrition screening, assessment, education, counseling, andcare planning). Many states are creating programs to providenecessary medical, social, and supportive HCBS, includinghome-delivered meals, nutrition education, and counselingservices (Kuczmarski and Weddle, 2005).

USDA Food Assistance ProgramsSeveral U.S. Department of Agriculture (USDA) foodand nutrition assistance programs ( www.fns.usda.gov/fns/ default.htm) are available to older adults. All USDAprograms are means tested (i.e., recipients must meetincome criteria). These programs are discussed further inChapter 10.

Supplemental Nutrition Assistance Program The Supplemental Nutrition Assistance Program (SNAP)program (formerly Food Stamps) is designed to end hungerand improve nutrition and health of low-income Americans.Beneficiaries use electronic benefit transfer (EBT) cards to

purchase certain foods at authorized retail food stores. Theprogram is operated by state and local welfare offices underUSDA guidance. Currently SNAP serves less than one thirdof eligible older adults—the lowest participation rate of alldemographic groups. Reasons for the low participation rateinclude the myth that only a $10 monthly benefit is provided, feeling stigmatized as a welfare recipient, feeling theapplication process is overly intrusive, eligibility confusion,mistrusting the EBT cards, and lack of outreach.

The goal of SNAP nutrition education is to make healthychoices within a limited budget and choose active lifestylesconsistent with the current Dietary Guidelines for Ameri-cans and MyPlate. State cooperative extension offices, nutri-tion education networks, public health departments, welfareagencies, and university centers generally provide the nutri-tion education. Unfortunately, little outreach specific toolder adults is offered.

Commodity Supplemental Food Program The Commodity Supplemental Food Program (CSFP)strives to improve the health of low-income Americans bysupplementing their diets with nutritious USDA commod-ity foods. It provides food and administrative funds to states,but not all are enrolled. In states, CSFP administration maybe located in diverse sites such as public health, nutritionservices, or agriculture departments. Eligible populationsinclude adults age 60 and older with incomes less than 130%

of the poverty level. Local CSFP agencies determine eligi-bility, distribute the foods, and provide nutrition education. The food packages do not provide a complete diet, but maybe good sources of nutrients frequently lacking in low-income diets.

Seniors’ Farmers Market Nutrition Program The Seniors’ Farmers Market Nutrition Program (SFMNP)is administered by state departments of agriculture, aging



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support for nutrition and quality of life extend beyond foodavailability and safety. Dietitian expertise is needed fornutrition assessment and care planning to meet special needssuch as type and amounts of macronutrients and micronu-trients, texture modifications, and quality of food choicesand presentation.

Surprisingly, fewer than 4% or 1.4 million seniors live inthe approximately 15,730 skilled nursing facilities (SNFs)

or LTC facilities (Centers for Medicare and Medicaid Ser- vices, 2010). The percentage of the population that lives ininstitutional settings, including nursing homes, increasesdramatically with age, especially for those older than age 85. These percentages have declined since 1990, likely becauseof healthier aging, the federal cost-containment policy torebalance LTC away from nursing homes to HCBS, andincreased availability of hospice (He, 2005).

Skilled nursing facilities are federally regulated underthe auspices of the Centers for Medicare and MedicaidServices; ALCs are subject to individual state regulations. More residents are there for short-stay, postacute care; thusmore comprehensive medical nutrition therapy is needed.

Nutritional care within long-term living facilities must bedirected toward identifying and responding to changingphysiologic and psychological needs over time that protectagainst avoidable decline. Attractive and palatable foodserved in an atmosphere that encourages eating indepen-dence, or assistance with eating provided when necessary,helps to promote nutritional well-being. For older adults,overall health goals may not warrant implementation ofstrict therapeutic diets that are often unpalatable and lessenquality of life. In terminal care for hospice patients, interventions include providing comfort foods and emotionalsupport for family and friends.

In 1987 Congress approved reform legislation as apart of the Omnibus Reconciliation Act (OBRA) to improvequality of care in SNFs by strengthening standards thatmust be met for Medicare and Medicaid reimbursement.SNFs are required to conduct periodic assessments to deter-mine the residents’ needs; to provide services that ensureresidents maintain the highest practical physical, mental andpsychological well being; and to ensure that no harm isinflicted. This is accomplished using the Minimum Data Set(MDS) , which is part of the federally mandated process forclinical assessment of residents of LTC facilities licensedunder Medicare or Medicaid. Section K of the MDS isspecific to nutrition and is generally the responsibility ofthe dietitian to complete, but can be done by nursing staff(Figure 21-4). This form documents “triggers” that may

place a resident at nutrition risk and therefore requiresan intervention. This assessment must be done at admissionand if there is a significant change in the resident’s conditionsuch as weight loss or skin breakdown. Reassessment isrequired quarterly and annually. The entire process is knownas the Resident Assessment Instrument (RAI) . It providesthe individual assessment of each resident ’s functionalcapabilities and helps identify problems and develop a careplan.

MF is an 84-year-old white woman resident in a skillednursing facility with unintentional weight loss. She

was admitted 3 months ago from the hospital after a hipfracture. She had been residing in an independent livingfacility for several years. She reports she has been eating

poorly because of difficulty moving around, being generallyuncomfortable, and states, “If I am not active I don’t need toeat so much.” Intake is less than 50% of regular diet. Noproblems chewing or swallowing are noted after a speechlanguage pathologist’s evaluation. Admission weight was 112pounds; current weight is 95 pounds. Self-reported height is5′ 3″ ; albumin, 3.2; Hgb/Hct, normal; total cholesterol, 135;and Mini Nutrition Assessment score, 3. Hip scans show slowfracture healing and no improvement in bone density; cur-rently being supplemented with calcium 1000 mg/d and vitamin D 400 IU/d. Blood pressure, 128/80 with furosemide(Lasix); other medications are lorazepam (Ativan), oxyco-done, senna (Senokot-S), docusate (Colace), and megestrol

acetate (Megace).

Nutrition Diagnostic Statement

Unintentional weight loss related to intake of less than 50%at meals with limited physical activity as evidenced by weightloss of 17 lb.

Nutrition Care Questions

1. Comment on the appropriateness of and use for eachmedication. Would you suggest any changes oradditional medications?

2. What strategies could you use to help improve thisresident’s food and fluid intake?

3. What suggestions are appropriate to promote fracturehealing and increase bone density?

4. Do you suspect that this client is constipated? What would you recommend in terms of food choices to deal with this?

CLINICAL SCENARIO

USEFUL WEBSITES

Administration on Aginghttp://www.aoa.govAmerican Association of Homesand Services for the Aging

http://www.aahsa.orgAmerican Association of Retired Personshttp://www.aarp.orgAmerican Geriatrics Societyhttp://www.americangeriatrics.orgCenters for Medicare and Medicaid Serviceshttp://www.cms.hhs.gov/International Longevity Centerhttp://www.ilcusa.org/



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Minimum Data Sethttp://www.cms.gov/IdentifiableDataFiles/10_LongTerm

CareMinimumDataSetMDS.aspMeals on Wheels Association of Americahttp://www.mowaa.org/Mini Nutritional Assessmenthttp://www.mna-elderly.com/default.html

National Association of Area Agencies on Aginghttp://www.n4a.org/National Association of Nutritionand Aging Services Programshttp://www.nanasp.orgNational Citizen’s Coalitionfor Nursing Home Reformhttp://www.nccnhr.org/National Institute on Aginghttp://www.nih.gov/nia

FIGURE 21-4 The Minimum Data Set, Section K version 3.0. (From the Centers for Medicare & Medicaid Services,Baltimore, MD.)

Swallowing/Nutritional StatusK0100. Swallowing Disorder

Signs and symptoms of possible swallowing disorder

Check all that apply

A. Loss of liquids/solids from mouth when eating or drinking

B. Holding food in mouth/cheeks or residual food in mouth after meals

C. Coughing or choking during meals or when swallowing medications

D. Complaints of difficulty or pain with swallowingZ. None of the above

K0200. Height and Weight - While measuring, if the number is X.1 - X.4 round down; X.5 or greater round up.

A. Height (in inches). Record most recent height measure since admission

inches

B. Weight (in pounds). Base weight on most recent measure in last 30 days; measure weight consistently, according to standardfacility practice (e.g., in a.m. after voiding, befo

nutrition in age

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