Transcript Enteral Nutrition Support

Nutritional Support in
Geriatrics
Dr A Norouzy
Associate Professor in Nutrition
Mashad University of Medical Sciences
Definition of Terms
• OLD – usual categorization
– Young Old – 65 -74
– Middle Old – 75 – 84
– Old Old
- 85 and older
• HETEROGENEOUS POPULATION
Geriatric Problems
• What geriatric
problems impact
nutritional
status?
Sensory Changes with Aging
• Decreased sense of smell due to
decreased olfactory cells
• Decreased vision
• Hearing loss
• Tactile loss
Sensory Changes with Aging
• Decreased number of taste buds
– i Loss of sweet
and salty
– Less loss of bitter
and sour
– Dry mouth prevents
adequate tasting
Geriatric Problems
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Weight Loss
Sarcopenia
Dehydration
Swallowing
Dementia
Pressure Ulcers
Constipation
Depression
Optimal Weight
• Weight is Primary Parameter
• Standard Tables vs. TRENDS
– Identify unintentional weight change
– Attention to trends
• Optimal Weight
– Maximize function and quality of life
– Minimize disease risk
Usual Weight Trends
Epidemiology
• Gradual Weight Gain – Middle Age
• Peak Weight at 75 years
• Gradual Weight Loss
after age 75
Unintentional Weight Loss
• Weight loss >5% in 30 days
• >7.5% in 90 days (three months)
• >10% in 180 days (6 months)
• Example:
– 5% 7-8# in 154# = 146#
– 10% 15# in 154# = 139#
Long Term Care Guidelines
American Healthcare Association
Identifying Weight Change
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Weight History
Change in Clothing Fit
Decrease in Functional Ability
Dietary Intake Records
These methods are readily
accessible and cost effective
Weight and Mortality
Potter, et al, 1988
Corrada, et al, 2006
Strategies: Calories
• Avoid unnecessary dietary
restrictions
• Encourage use of
nutrient dense foods
• Use more frequent meals plus
supplements or snacks
Strategies: Calories
Practical Suggestions
• Use foods that are well liked
frequently
• Provide double portions of
favorite foods
• Add calories by using sauces,
gravies, toppings, and fats
• Emphasize calorie containing
liquids to meet fluid needs
Obesity
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h numbers reaching older age as obese
(30.5% in NHANES)
h physical and cognitive disability
• h risk of dependency and
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institutionalization
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h health care costs, poor health
outcomes, mortality
Houston, et al, JADA, Nov. 2009
Obesity Treatment
• Goal: To better manage health and
maintain independence longer
• Minimize loss of muscle mass
– Adequate protein
– Exercise (aerobic and resistance)
• Minimize loss of bone density
– Adequate calcium, Vitamin D
– Exercise (weight bearing)
• Adequate nutrient intake
Sarcopenia
• Definition: Loss of muscle mass in aging.
• Results: Lower basal metabolic rate
– Weakness
-Decreased Functional Status
– Reduced Activity Level
– Decreased Bone Density
• Practical Application
– Progressive Resistance Exercises
– Adequate Protein
Protein
•Higher protein intake required
to maintain nitrogen balance
•Contributors:
–Lower energy intake
–Impaired insulin action
–Decreased efficiency of
protein utilization
J.Nutr.Healthy Aging, 2006
Protein
•1.0-1.25 gm/kg/day
•At least one high protein food
at each of three meals
•Physical activity to maintain
muscle mass
-Exercise against resistance
Dehydration: Causes
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Decreased thirst sensation with aging
More dependent on others to obtain fluid
Decreased ability to concentrate urine
Increased incidence of incontinence with
self-imposed fluid restriction
• Increased use of medications contributing
to dehydration
• Increased losses: vomiting, diarrhea, fever
Dehydration: Symptoms
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Decreased Skin Turgor
Dry Mouth and Mucosal Membranes
Decreased Urine Volume
Darker Urine
Constipation
Acute Weight Loss
CONFUSION
Dehydration
Practical Application
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Treat Cause
Set Fluid Goal
Goal: 30 cc/kg or 1 cc/Kcal
Replace Additional Fluid Losses
Drink Fluid At and Between Meals
Use Foods Which Have Fluid Value
Fluid:Nutrient Comparison
Fluid
Free Water (cc) Calories/Protein
Water
240 cc (100%)
0/0
Juice (Apple)
210 cc (88%)
111/0
Whole Milk
214 cc (89%)
150/8
Instant
Breakfast
Fruit Beverage
Supplement
217 cc (80%)
250/13
191 cc (79%)
300/10
Swallowing Problems
S
Swallow is difficult or hard to initiate
W Wet sounding voice
A
Aspiration pneumonia in history
L
Loss of fluid through the nose
L
Leakage of food or liquid out of mouth when eating
O Overt coughing or choking with oral intake
W Weight loss with inadequate nutritional intake
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Involve Speech Pathologist and others
N Nutrient Density
G Go for Least Restrictive
Dementia
• Weight Loss Primary Nutritional Problem
• Stage of Disease Important
• Eating Behaviors
Eating Behaviors: Overview
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Eating is NOT just food
Barometer of well being
Social interaction
Symbolic of life
Pressure Ulcers
• Screening Tool: (Example – Braden Scale)
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Sensory Perception
Moisture
Activity
Mobility
Friction and Sheer
– Nutrition
• Cooperation and Collaboration Needed
– Nutrition is only one component
Pressure Ulcers: Nutrition
• Protein: 1.25 to 2.0 gm/kg
• Vitamin/Mineral Supplementation
– Useful with poor intake or depletion
– Vitamin C: 1 to 2 gm/day
– Zinc Sulfate: 220 mg/day
Robertson’s Rule of 2’s
Food Item
Amount
Dietary Fiber
Apple+Orange
2 medium size
8-10grams
Whole Wheat
Bread
2 slices
4 grams
Fresh Fruit
2 pieces
4 grams
Vegetables
2 servings
4 grams
Total
20-22 grams
Geriatric Problems
Principle:
Avoid
unnecessary
dietary
restrictions.
Osteoporosis
•High incidence of osteoporosis
–33% of women 60-70 years old
–66% of women > 80 years old
•Less efficient absorption of
calcium and Vitamin D
•Reduced exposure to sun =
reduced conversion of
inactive D to active D
•Supplementation essential
–1200-1500 mg/day
Serum 25-hydroxyvitamin D
• <20 ng/mL
Deficiency
• 20-29 ng/mL
Insufficiency
• 30-80 ng/mL
Optimal Level
• >80 ng/mL
Possible Toxicity
Prevelance of Deficiency
• 40 to 100% of U.S. & European
elderly men & women living in
the community are deficient in D
• >50% of postmenopausal women taking
medication for osteoporosis have suboptimal
levels of D
(<30 ng/mL)
• 65% of Iranian female adult are vit D deficient
Prevention & Maintenance
• 1000 IU Vitamin D3 per day
• Daily sun exposure
5 to 30 minutes
10 am to 3 pm
Treatment of Deficiency
• 50,000 IU of Vitamin D3 weekly
for 8 weeks
• Repeat for another 8 weeks if
25-hydroxyvitamin D <30ng/mL
Oral Supplementation
• Cochrane Systematic Review
• Effectiveness of nutritional supplements
in elderly at risk for malnutrition
• Review of 62 trials
– 10,187 randomized patients
– Maximum duration of intervention: 18 months
•Milne, AC, et al, Protein and energy
supplementation in elderly people at risk from
malnutrition. Cochrane Database of Systematic
Reviews, 2009, Issue 2.
Oral Supplementation
• Significantly improved mortality in
undernourished
• Small, consistent weight gain in 42 trials
• Reduced risk of complications in 24 trials
• No evidence of functional improvement
• No reduction in Length of Stay
Oral Supplementation
Practical Suggestions
• Product Acceptance
• Taste Fatigue
• Supplementation not Meal Replacement
Oral Supplements
• Carbohydrate Powder
• Protein Powder
• Carbohydrate & Protein
‫متشکرم‪.‬‬