Transcript Slide 1
Nutrition Aspects in Elderly
Pranithi Hongsprabhas
Division of Clinical Nutrition, Department of Medicine, Faculty of
Medicine, KKU
Outline
Nutritional disorders
Over nutrition
Under nutrition
Etiology of malnutrition
Nutrition related problems
Introduction
Changes in aging nutritional risk
Organ system reserve
Weaken homeostasis control
heterogenicity of response
Genetic
Environment
Geriatric failure to thrive (FTT)
FTT: state of decline
Decline in vitality…
The causes of deterioration: not identifiable or
irreversible..
Undergo a process of functional decline,
progressive apathy and loss of willingness
to eat and drink that culminate in death
4 Syndromes of FTT
Impaired physical function
Malnutrition
Depression
Cognitive impairment
Manifestation
Weight loss > 5% of baseline
Appetite
Poor nutrition
Inactivity
Accompanied by
Dehydration
Depressive symptoms
Impaired immune function
Low cholesterol
Undernutrition syndrome in elderly
More common
home 2-32%
Long term care 25-60%
Institution 1-83%
Hospital 30-65%
Greater impact: less able to adapt to
underfeeding
Less frequent hunger
Not regain total # of weight
Consequences
Functional disabilities
Nosocomial infection
Perioperative complication
Morbidity, mortality
Longer LOS
Increased health care expenditure
Etiology of under nutrition
Inadequate
Altered
intake (starvation)
absorption
Nutrient loss
Nutrient
metabolism
Weight loss in elderly
Inadequate intake
Inflammatroy effect of illness (cachexia)
Muscle atrophy (sarcopenia of elderly)
Nutrient intake in elderly
Anorexia
Physical illness: organ dysfuction, cancer,
infection
Mental illness
Medication
Poor oral/dental health
Dysphagia
Visual impairment
Influence of dental status on dietary intake
Mean percentage of nutrient intakes
120
50
Adequate dentition
Use of dentures
45
100
40
of dentures
inadequateUse
dental
status
Inadequate dental status
35
3580
%
30
2560
47.9
Adequate dentition
32.8
28.6
21.6
22.7
P<0.001
P<0.01
20
40
15
1020
5
0 0
Calories
Protein
Poor appetite
Iron
Folic Dyspepsia
B6
Vit C
GI problems in elderly and their relations
to Nutritional disorders
Dysphagia
Oropharygeal
Esophageal
Atrophic gastritis
Delayed GET
Dyspepsia
Diverticulum
Colonic cancer
Atrophic gastritis
Type A: pernicious
anemia (autoimmune)
Type B
Chronic inflammation
Associated with HP
Secretion of
Acid
Pepsin
Intrinsic factor
40
% Atrophic gastritis
35
30
25
20
15
10
5
0
60-69
70-79
80+
Krasinski SD J Am Geriatr Soc. 1986
Nov;34(11):800-6.
Nutritional consequence of atrophic
gastritis
availability and
absorption of B12
(food-cobalamin
malabsorption)
Ca absorption
non heme Fe
absorption
500
Serum B12 (pg/dl)
450
400
350
300
250
200
150
100
50
0
Young adult
Normal elderly
elderly with
atrophic gastritis
Krasinski SD J Am Geriatr Soc. 1986 Nov;
34(11):800-6.
B12 deficiency
Megaloblastic anemia
Neurological damage
SCDS
Dementia
Atherosclerosis (hyperhomocysteinemia)
Nutrition metabolism related to body
composition changes
Body composition
Fat free mass
Fat mass
Energy expenditure
Decreased: with aging and lean body mass
Increased:
Parkinsonism
Cancer
Infection
Chronic cardiac failure
Chronic pulmonary diseases
Nutrition metabolism related to body
composition changes
Protein requirement: increased
catabolism in diseases
synthesis
Cachexia
Cancer
Cardiac
Pulmonary
Chronic infection
energy requirment ~10-15 %
protein requirement
Hormonal control: cortisol, catecholamine
Cytokines: TNF, IL-1, IL-6
Sarcopenia:
~poverty of flesh
lean body mass
Concomitant fat
mass
Multifactorial disorders
sex hormone: testosterone/DHEA
GH and IGF-1
cytokine production
Neuromuscular changes
Physical inactivity
Malnutrition
GH secretion
CNS input (loss of motor neurones,
changed motor unit activation)
Proinflammatory
cytokines
Muscle mass
fat mass
Estrogen/Androgen
Sarcopenia
Muscle quality
Weakness
Inactivity
Disability
Morbidity
Mortality
metabolic
reserve
Consequence of Sarcopenia
energy expenditure
insulin sensitivity
muscle strength
risk of disability
risk of fall
risk of mortality
Distinguishing sarcopenia from cachexia
Sarcopenia
Cachexia
Not affected
Not affected
Suppress in early
May
Cholesterol
N
May
Cortisol
May
Inflammatory disease
Response to refeeding
Not present
Resistant
Present
Resistant
Pathway
Not lead to cachexia
May lead to sarcopenia
Appetite
Food intake
BW
FFM
Alb
Clin Nutr 2006;26:389-99
Exercise Training and Nutritional Supplementation
for Physical Frailty in Very Elderly People
Mean (±SE) Changes in Energy Intake in the Four Study Groups
Mean Changes in Muscle Strength after
Fiatarone MA et al. NEJM 1994; 330:1769-1775
Nutritional screening
Mininutritional assessment (MNA)
Screening
Food intake (3mo)
Wt change (3mo)
Mobility
Psychological or acute disease
Neuropsychological preoblems
BMI
Markers
Screening tools
Hx
MNA
Wt loss
Dietary Hx
Medical Hx
Anthropometry
Lab
CBC
Alb
Chol
Nutritional Rx:
Rx causes of poor intake
Nutritinal intake
Diet
Oral nutritional supplement (ONS)
Enteral tube feeding (ETF)
Possible strategies to improve oral intake
Risk
Interventional strategies
Loss of appetite
Check drug
Personally chosen food, Fortified menu
appetizer
Chewing problems
Dental care, oral hygiene, mushy food
Swallowing problems
Speech Rx, ETF
Difficulties preparing
food
PT, nursing assistance
Chronic pain
Analgesia
Depression
Check medication, medical Rx
Social isolation
Social service, meals on wheels
Enteral nutrition
Oral nutritional supplement
1200
ONS
Control
1081
957
1000
Meta-analysis
of protein
energy supplement (ONS)
800
600
400
200
5.36 (1.73 to 8.99)
45.9
0
Potter J, et al ใ BMJ 1998;317;495-501
Energy intake (kcal)
38.3
Protein intake(g)
Bourdel-Marchasson I, et al Nutrition. 2000 Jan;16(1):1-5.
ETF
Meta-analysis of protein energy supplement (ETF)
4.04 (3.15 to 4.94)
Bourdel-Marchasson I, et al Nutrition. 2000 Jan;16(1):1-5
Potter J, et al ใ BMJ 1998;317;495-501
Obesity in elderly
Diseases associated with obesity
Cardiovascular, stroke
HTN
DM/Metabolic syndrome
Dyslipidemia
Cancer
Breast
Endometrial
Colorectal
GERD
Cholelithiasis
NASH
OSA/OHS
Asthma
OA
Gout
Infertility
PCOS
incontinence
Association of BMI and Wt Change with All-Cause Mortality in the Elderly
American Journal of Epidemiology2006;163:938
Degree of obesity and mortality in elderly
NEJM 1999;341:427-34.
Relation between in Wt and RR of Type 2 DM,
HTN, CHD, and Cholelithiasis.
FU 10 yr, age 40-65 yr
NEJM 1999;341:427-34.
FU 18 yr, age 30-55 yr
Voluntary Wt Reduction in Older Men Hip Bone Loss: The
Osteoporotic Fractures in Men Study
Association of Mild to Moderate Weight Loss with All-Cause Mortality*
Andres, R. et. al. Ann Intern Med 1993;119:737-743
Treatment strategies
Preventing weight gain and overweight
healthy weights and
avoiding further weight gain among those
already overweight
are important public health goals.
Weight reduction in pts with mobility
problem
Therapeutic lifestyle control