The Complex Relationship Between Depression and

Nutrition in the ElderlyA presentation for providers of long term and in-

home care

General Indicators of Health Status● Nutritional Status!

● Dietary Intake!● Impact of chronic disease!

● Psychological Status!● Memory!● Emotional well-being

Factors That May Affect Nutrition Status in the Elderly!!

● Social Factors!● Biological Factors!● Psychological factors

Social Factors● Level of food security!● German et al report older adults reporting food

insufficiency are ten times more likely to be depressed.1!

● Eating alone, eating environment: Kimura et al found that among a group of elderly ! persons in Japan, those who ate alone experienced significant depressive symptoms2!

● Lower socioeconomic status1!

● Skipping meals to save money

Biological factors3

● Risk of altered dietary intake increases with age related changes

Biological Factors3

● Certain medications affect nutritional status!● Polypharmacy4!● Side effects!● Some medications may alter taste sensation!

● Some medications may require restriction of certain foods (see next slide)!● Example: warfarin!● Monitor vitamin K intake!● Restrict spinach, kale

Food and Drug Interactions Download From: http://www.todaysdietitian.com/newarchives/121610p26.shtml

Drug Food Increase Drug Effect Decrease Drug EffectSome statins Grapefruit, pomegranate, and cranberry

juices

(eg, Lipitor, Zocor, Mevacor, Advicor)

†

Antidepressants Chocolate and other foods containing tyramine

(MAO inhibitors) †Allergy medications (eg, Allegra)

Black pepper †

Potentially all drugs metabolized by P450 liver enzymes

Black tea †

Cancer drugs Beer (eg, tamoxifen) †Anticlotting agents Fatty fish (eg, Plavix) †Beta-blockers Meat (hypertension medications) †

Blood thinners Leafy greens (eg, Coumadin) †Beta-blockers Natural licorice (hypertension medications) †

Antibiotics Milk and calcium-fortified juices (eg, Cipro, tetracycline) †

Polypharmacy4

● Polypharmacy may be linked to malnutrition in some elderly patients!

● Use of multiple prescription drugs!● May or may not be clinically indicated!● Pharmacist should be part of health care team to

monitor prescriptions for compatibility and interactions !● Drug interactions!

● Impact of medications on nutrition!● Food and drug interactions

Psychological Factors!

●Dementia!●Alzheimer’s!●Depression

Psychological Factors!● Dementia/ Alzheimer's5!

● Patients may forget to eat or eat twice because they forgot that they ate earlier!

● Patients who wander or pace may have increased caloric needs!

● Weight loss and malnutrition complications

Psychological Factors● Depression3!

● 1 to 5 % of older adults suffer from depression, 13.5% in long-term care6!

● Chronic disease experienced within the context of chronic conditions worsens symptoms of both the chronic disease and the depression7!

● Symptoms of depression can be different in the elderly and can often be confused with symptoms of chronic disease3

Symptoms of Depression in the Elderly3

!● Lack of interest in usual activities!● Depressed mood!● Anxiety, agitation, indecisiveness!● Vague complaints of pain or lack of sleep!● Memory problems!● Loss of appetite!● Overeating

Risk Factors for Depression in the Elderly3

!● Family history!● Previous diagnosis!● Some types of chronic disease!●Parkinson’s, Alzheimer’s, MS!

● Substance abuse!●Certain medications!● Single/divorced, loss of spouse

Depression and Nutrition!

●It is unclear whether depression is caused by poor diet, or whether depression leads to poor dietary habits that increase the incidence of malnutrition in the elderly; however, it is clear that the two are inextricably related, especially in the elderly.

Nutrition Factors Related to Depression● Depression often co-morbid with other chronic

diseases such as diabetes or cardiovascular disease3!

● Some depression medications can negatively impact nutrition3!

● Malnutrition and vitamin/mineral deficiencies are common3!

● Vitamin deficiencies related to depression8!

● Geriatric failure to thrive3!

! !

Vitamin Deficiency and Depression7

!● Vitamins B12 and other B vitamins play role in producing

chemicals in the brain that regulate mood8!

● Deficiencies in B12,B6 and folate may be linked to depression8!

● Low levels of Vitamin D linked to depression, but evidence is not conclusive3,9!

● May be related to behavior of depressed individual rather than the cause of depression, i.e. a depressed individual may spend less time outdoors!

● Vitamin D may improve serotonin levels

Dietary Reference Intakes for B12, B6, Folate and Vitamin D● Males > 70 years old: !

● B12: 2.4 μg/d!● B6: 1.7 mg/d!● Folate: 400 μg/d!● Vitamin D: 15 μg/d!

● Females > 70 years old: !● B12: 2.4 μg/d!● B6: 1.5 mg/d!● Folate: 400 μg/d!● Vitamin D: 15 μg/d

Geriatric Failure to Thrive!● “Downward spiral” of interrelated conditions3!

● Decreased appetite!● Weight loss!● Malnutrition!● Depression!● Decreased physical function!● Decreased cognitive function

Antidepressant Medications that Affect Nutrition3

● Tricyclic and tetracyclic antidepressants are not usually prescribed for older adults!

● SNRI’s!● Side effects include: Nausea, dry mouth, and constipation!

● Atypical!● Side effects include: Suppress appetite, increase lipid levels and

cholesterol!● MAOI’s!

● Side effects include: Diarrhea, nausea, constipation, weight gain!● SSRI’s!

● Side effects include: Nausea, vomiting, weight gain or loss, diarrhea, dry mouth

Course of Action for Intervention3

!● Identify seniors at risk for depression and

malnutrition!● Appropriate referrals!● Team approach: nurses, physician, RD, caregivers3!

● Identify and treat the depression, or dementia3!

● Psychotherapy!● Pharmacotherapy

Intervention3 (continued)

!● Nutrition related assessments, involve RD!

● Food diary, 24-hour recall!● Identify and treat other problems decreasing desire to

eat!● Side effects of medications!● Mobility, strength issues!● Dental problems

Intervention3 (Continued)

!● Review of medications!

● OTC!● Herbal supplements!

● Recommend least restrictive diet possible!● Cost benefit analysis regarding need for restriction!

● Assess need for supplementation

Intervention3 (continued)

!● Eating environment !

● Pleasant, easy to access, socialization!● Availability of food!

● Address financial concerns!● Counsel regarding availability of social services!

● Cultural considerations!● Do preferences modify dietary intake?

Successful education and empowerment involves both the patient/resident and the caregiver● "It's interesting how the views of nutrition in the

elderly have changed in the last five years. We used to focus on the amount of calories we could get into people. Now we are preaching eating close to home, cutting out [bad] fat and sodium, whole foods etc. My residents know the difference between quinoa and barley (and have eaten both). They want to know where their meat comes from, and appreciate the fact that we make everything from scratch.”10!

● Kara Emig, RD Holly Creek Assisted Living

References● 1. German L, et al. Depressive symptoms are associated with food insufficiency and nutritional deficiencies in poor

community dwelling people. The Journal of Nutrition, Health and Aging. 2011 Jan; 15(1):3-8.!● 2. Kimura Y, at al. Eating Alone Among Community Dwelling Japanese Elderly: Association with depression and Food

Diversity. The Journal of Nutrition, Health and Aging. 2012 Aug; 16(8):728-31.!● 3. Phillips RM. Nutrition and Depression in the Community Based Oldest Old. Home Health Care Nurse. 2012, vol. 30,

number 8, pp. 462-471.!● 4. Jyrkka J, et al. Polypharmacy and nutritional status in elderly people. Current Opinion in Clinical Nutrition, and

Metabolic Care. 2012 Jan;15(1):1-6.!● 5. Guerin O, et al. Nutritional Status Assessment During Alzheimer's Disease: Results After One Year. The Journal of

Nutrition, Health and Aging. 2005; 9(2):81-4.!● 6. Centers for Disease Control and Prevention, Division of Adult and Community Health, National Center for Chronic

Disease Prevention and Health Promotion. (2010). Depression is not a normal part of aging. Retrieved fromhttp://www.cdc.gov/aging/mentalhealth/depression.htm!

● 7. National Institute of Mental Health. (2011). Depression (NIH Publication No. 11-3561). Retrieved fromhttp://www.nimh.nih.gov/health/publications/depression/complete-index.shtml!

● 8. Skarupski, K. A., Tangney, C., Li, H., Ouyang, B., Evans, D. A., & Morris, M. C., (2010). Longitudinal association of Vitamin B-6, folate, and Vitamin B-12 with depressive symptoms among older adults over time. American Journal of Clinical Nutrition, 92, 330-335. !

● 9. Bertone-Johnson E. Vitamin D and the occurrence of depression: causal association or circumstantial evidence? Nutrition Reviews. 2009: 67(8) 481-492.!

● 10. Emig K. Interview: 16 June, 2013.!● 11. Hetherington, M. M., Anderson, A. S., Norton, G. N., & Newson, L. (2006). Situational effects on meal intake: A

comparison of eating alone and eating with others. Physiology & Behavior, 88(4-5), 498-505.!● 12. Gebretsadik, M., & Grossberg, G. T. (2007). Nutrition and depression. In J. E. Morley & D. R. Thomas (Eds.). Geriatric

nutrition (pp. 373-397). Boca Raton, FL: CRC Press.