Transcript Undernutrition in the old age-costs and treatment implications

Undernutrition in the old agecosts and treatment implications
Danit R Shahar, RD, PhD
Danit R Shahar, RD, PhD
The S. Daniel Abraham International Center for
health and Nutrition
Ben-Gurion University-Israel
Clinical dietitian
PhD in nutrition epidemiology
PhD Thesis: Factors associated with dietary
intake and eating habits of community dwelling
elderly people living in Pittsburgh, USA
Areas of interest:
Dietary assessment methods
Factors associated with undernutrition among
the elderly
Personal Statement
My professional commitment is to study and
develop research programs and teach students
of all health disciplines the topic of geriatric
nutrition.
The work may create these people as leaders in
their communities and thus change people
views and attitudes toward older people.
Learning objectives:
To understand the concept of undernutrition
among the elderly population
To understand the implications of undernutrition
in terms of health consequences, cost and
treatment
To be familiar with the main risk factors and
causes for nutritional deterioration and
deficiencies
To understand the basic concepts of dietary
assessment of the elderly population
Nutritional status of the elderly populationthe prevalence of undernutrition
 COMMUNITY SURVEYS:
 35-40% < 2/3 RDA
calories (Bidlack 1992)
 70--78%< RNI* calories (Payette, 1995)
 48-60% < RNI* Protein (Payette, 1995)
 NURSING HOME SURVEYS:
 5-18% < RDA calories (Rudman, 1989)
 0-33% < RDA protein (Rudman, 1989)
*RDA=Recommended Dietary Allowances
**RNI=Recommended Nutrient Intake-Canadian
recommendations-Different approach than the RDA
Nutrient
NHANES I NHANES II NHANES III
(1971-74)
(1976-80)
(1988-91)
Calories 16%-18%
Riboflavin 6%-36%
Vitamin B6 50%-90%
Vitamin A 42%-65%
Vitamin C 23%-58%
Calcium 40%-50%
20%-30%
7%-13%
54%-69%
22%-36%
22%-31%
30%-43%
25%-40%
15%-20%
25%-50%
25%-30%
15%-25%
25%-50%
Table I:Percentage of inadequate intake of nutrients
based on NHANES I II and III data
(The NHANES III data is based on NCHS/CDC)
Dietary intake as compared with
the DRI: (Negev Nutrition Study):
120
100
80
Percent of
the DRI
60
40
20
0
Ca
Men
Women
N
F
Ma
V
V
V
gne it B6 it B1 it B2 iacin olic a
m
cid
ziu
m
lciu
Selected nutrients
Do we treat undernutrition?
McWhirter & Pennington BMJ, 1994 -Only
2% of undernourished hospitalized patients
are being treated. 5% were referred to
treatment during their hospitalization..
During hospitalization 64% of the patients
have lost weight.
70% showed improvement in their nutritional
status after treatment.
General consequesnces of
undernutrition:
Weight loss is associated with a decline in
function ability (Allison, 1992)
Delayed wound healing (Hill, 1992)
Impairment of the immune system which may
increase the risk and consequences of
infection (Chandra, 1988)
With severe weight loss, both cardiovascular
and gastrointestinal functions are impaired
Malnourished people may become depressed
and apathetic (Brozek, 1990)
General consequesnces of
undernutrition II:
Loss of muscle strength (Lesourd BM, 1995)
Increase in fractures
Increased incidence of pressure sores
Specific micronutrient deficiencies
Malnutrition and post-surgical
complications (Meguid, 88)
P<0.001
P<0.001
Well nourished
Malnourished
Complication rate
Post-operative
mortality
Cost of a stay in hospital in malnourished
and well nourished patients with or
without major complications (Reilly, 88)
Cost of average
hospital stay
$12,683
Malnourished pt. with major
complications (n=67)
Normally nourished pt. With
$7,375
major complications (n=20)
Malnourished pt. With no
$3,469
complications (n=312)
Normally nourished pt. With no $2,968
complications (n=304)
Energy balance:
Naturally there is a decrease in energy needs.
Till 70 years old there is a positive energy
balance associated with weight gain
After age 70 we can see a negative balance
associated with weight loss. Lean body mass
and body fat tend to be reduced (Morley)
Weight loss in the older age is associated with
increased mortality and morbidity
Weight, weight change, and mortality in a
random sample of older community-dwelling
women -JAGS1414-1409 :47
Low
Average
High
Total
%
Loss
No Change
Gain
Cycle
Weight change categories
White older community-dwellers women are at increased risk of mortality
if they are underweight, lose weight or weight cycle
RR for mortality according to BMI
among older people 70 years and older:
RR
AJCN 2001 55(6):482-492
1,8
1,6
1,4
1,2
1
0,8
0,6
Males
Females
-2
.7
14
22
2
9.
-3
.6
28
5
V
8.
Q-2
.5
26
4
IV
6.
Q-2
.7
24
6
III
4.
Q-2
II
Q-
1
Q-
2.
6
Risk facrots for undernutrition
Physiological factors:
– Impaired senses of
smell/taste
– Dental problems
– Decreased gastric acid
secretion
– Medication/Medical
problems
– Decreased mobility
affecting purchase and
preparation of foods
Drug therapy in the old age Nutritional aspects
Multiple medication due to co-morbidities
Effect of medications on digestion and absorption
Direct effect of medications on appetite
Medication may decrease or distort taste and
smell
Certain medication may cause oral dryness
Certain medication may decrease mobility of the
stomach and gastrointestinal tract
Diarrhea and decreased absorption (antibiotics)
Behavioral aspects
Changes of nutritional needs (diuretics)
Medication and appetite:
Increase appetite and
food intake
Steroids
Sex hormones
Antipsychotic
Antihistamin
Prokinetic
Kanavis
Decrease appetite and food intake
Sympathomimetics
Anti-parkinsonian [L-dopa,
Sinemet]
Antidepressants, SSRI,
Prozac and realted Rx
Xantines [Theophylline]
Digitalis
RISK FACTORS FOR MALNUTRITION:
(cont)
Socioeconomic factors:
– Declining income and retirement
– Smaller household size
– Loss of spouse
– Isolation and institutionalization
 Psychological factors:
 Depression
 Stressful life events
 mental confusion
Eating habits and caloric intake – NNS results:
Decreased appetite, low snacking, gastrointestinal problems
and poor health status were associated with low caloric intake
Caloric intake by risk factors and gender
Click for larger picture
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Known risk factors for decreased dietary intake
men-no
women-yes
women-no
Other risk factors for undernutrition
among the elderly population:
Eating less than needed-fewer products and
smaller meals or portions
Decreased appetite and early satiety
Changes in energy regulation
Changes in the levels and function of
neuropeptides (NO decrease, CCK
increase>>>early satiation)
Decreased enjoyment of eating
What patients are at risk for nutritional
deterioration?
Cancer
Cardiovascular Heart Failure
Chronic Obstructive Pulmonary Disease
(COPD)
Post-surgery
Gastrointestinal diseases
Liver Cirrhosis
Renal Failure
Depression
Dementia
These diseases may be hypermetabolic and / or
induce anorexia
What are the most typical
nutritional deficiencies in the old?
Vitamin B12 (Usually not dietary)
Folic acid
Vitamin B6
Antioxidants vitamins
Zinc
Vitamin D
Calcium
Vitamin K
Factors associated with nutritional
deficiencies
Eating lower nutritional quality foods such as
bread and butter exclusively
General and specific deficiencies due to higher
needs, co-morbidity and multiple medications.
Physiological and pathophysiological changes
in the gastrointestinal system impact the
ingestion and digestion of nutrients
 Unnecessarily restrictive diets
Socioeconomic
Psychological
Physiological
Loss of motivation/will to eat
General deterioration
“I am not important to anyone”
Nutritional
deficiencies
Eat small amounts
Intervention strategies:
Treatment of risk factors
Better
eating
Regaining physical
and emotional strength
Quality of life improve
Weight as a key measurement for
nutritional status
Weight history is one of the simplest and
most consistent measure (Mobarahan 1991)
Weight change is a key variable in nutrition
assessment in the elderly (Jeejeebhoy 1991)
Recent weight loss is a sensitive indication of
individuals at nutritional risk (Fogt 1995)
Weight loss as an indication of
nutritional deterioration
An involuntary weight loss of 10% of more
especially over a short period of time
weight loss of 1 kg per week, 2 per month.
Weight loss trend over time
Nutritional assessment:
Assessment of appetite
Are all food groups included in each meal
(5 colors of food per meal)
Enjoyment of eating
Use of Mini Nutritional Assessment
(MNA) or eating behavior questionnaires
Biochemical and clinical assessment
Recommendations:
Dietary assessment as part of geriatric assessment
Healthy eating
Encourage Snacking
High quality drinks or supplements (shakes)
Caution with prescribed “medical” diets
Judicious use of medication
Treating risk factors (depression)
Fortified foods
Supplements [energy!!! + nutrients]
Encourage weight stability, avoid loss!!!