Nutrition In The Elderly
    By Ms. Ann Scheve MS, RN-C

    Good nutrition contributes to an active healthy and productive older person's life.  Likewise, undernutrition should be a suspect in older persons who have multiple disabilities and diseases and require health care resources. Nutritional deficits have been shown to contribute significantly to many diseases that occur in the elderly.  With increase in age, there is an increase risk of developing nutritional deficiencies that can lead to such debilitating consequences like functional dependency, morbidity and mortality.  This article will review nutritional requirements, assessment and management of nutrition in the elderly.


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    The Food and Nutritional Board of the Institute of Medicine no longer uses the term, Recommended Daily Allowances.  Rather, they use Dietary Reference Intakes (DRI).  DRIs are reference values to estimate the nutrient intakes to be used for planning and assessing diets for healthy people.  Many of the DRIs for older adults are not based on large studies of older people, rather they are derived by extrapolation from data obtained for younger persons. The DRI adjustments for older adults have been made based on the reduction in physiologic function, changes in body composition and metabolic adaptation in adults over 51 years of age and then again over 71 years of age. 

    Table 1 shows the most current DRIs.  Additionally, healthy older adults have different nutritional needs than those older adults that are frail with many diseases.  It is impossible to include all the additional requirements for specific clinical conditions in this article.  The authors recommend that with acute or chronic diseases, the consultation of a dietitian is necessary so adequate intake can be calculated on an individual basis.
     
    Table 1    DRI for older adults over 70 

    RequirementsHealthy Elderly Women Healthy Elderly MenAdditional comments
    Protein1g/kg body weight1g/kg body weightAcute and chronic diseases increases protein requirements
    Carbohydrate
         		55-60% of total calories/day55-60% of total calories/day 
    Fat30% of total calories/day30% of total calories/dayHealthy elderly in their 60s-70s but overweight, hypercholesterolemic and/or hypertensive, should reduce calories, fat and sodium under the supervision of a clinician. Aging does not alter any of the specific requirements for any essential lipids
    Water1mL/kcal or 30mL/kg body weight1mL/kcal or 30mL/kg body weightDehydration and Diarrhea   The amount of fluid that is lost must be replaced, and replaced soon after the fluid loss. Patients and families must be educated to the importance of maintaining adequate fluid intake at all times, especially with acute conditions.
    Calories1,900kcal/day or 30kcal/day2,300kcal/day or 30kcal/day 
    Calcium1200mg-1500mg1200mg-1500mg 
    Zinc8mg11mg 
    Iron8 mg8mg 
    Selenium55mcg55mcg 
    Vitamin C75mg90mg 
    Thiamin1.1mg1.2mg 
    Folate 400ug400ug 
    Vitamin B122.4ug2.4ug 
    Vitamin D600 IU600 IUIf no sun exposure, 800-1600 IU per day.
    Vitamin E15 IU15 IU 

     
    This table was adapted from The National Academies of Sciences, March 2001.1
     
    A proper and continuous nutritional assessment of a patient's nutritional status is important to identify those patients that are at risk.  A comprehensive nutritional assessment consists of a history, physical exam, anthropometrical measurements, biochemical and immunologic measurement.  See Table 2
     
      Table 2          Nutritional Assessment in Older Adults

    HistoryPhysical Examination
    Past medical historyAnthropometrics
    Current symptomsMuscle wasting, skin turgor
    History suggestive of depressionOral/dental status
    Use of tobacco, alcohol or illicit drugsSigns of vitamin or mineral deficiency
    Current medications including OTCsFunctional status
    Socioeconomic statusSwallowing difficulties
    Weight loss (>10% in 6 months or > 5% in 1 month) 
    Alteration in functional status 
    Diagnostic StudiesDiagnostic Studies continued
    Comprehensive metabolic panelChest radiograph
    Serum levels of total protein, albumin, prealbumin, total cholesterol Urinalysis
    Thyroid function testsFecal occult blood testing
    Serum vitamin and mineral levels: Iron, folic acid, vitamin B12Energy panel
    Dietary AssessmentAdditional Studies
    Daily energy intake and recent changesSpecial assessments prn

     
    Keeping in mind the need to be judicious with time, there are short tools that can be used to systematically evaluate those older adults who may be at risk for nutritional deficits.  John Morley developed a short tool, (Table 3) SCALES.2  It screens for depression, weight loss, eating habits, functional ability and laboratory data.  It can be easily used in the office as well as in the nursing home setting.

    Table 3              The Nutritional Risk Screening SCALES

    SadnessYesavage Geriatric Depression Scale of 15 or greater out of 30.
    CholesterolLess than 160mg/dl
    AlbuminLess than 4g/dl
    Loss of weight5% in one month and/or 10% in 6 months
    EatProblems feeding self either because of physical or cognitive problems
    ShoppingSufficient money to buy food and the ability to obtain and prepare it

      
    The SCALES assessment tool enables the practitioner to evaluate six essential risk factors that can be indicative of nutritional deficits.  Depression is a common, treatable cause of weight loss.  In a study conducted in a nursing home, one third of the patients that were malnourished were found to be depressed.  Once the depression was treated, 70% of the cases returned to normal weight. 

    Total cholesterol is a useful nutritional assessment.  A cholesterol level of less than 160mg/dl is considered an indicator of undernutrition.  Normal aging is not associated with a significant decrease in albumin level.  A level below 4.0g/dL is an indicator of protein energy malnutrition.  Lower levels are associated with increased mortality.  Unintentional weight loss of more than 10% over a 6-month period and /or more than 5% in one month has clearly been shown to be associated with increased mortality. 

    The risk of malnutrition is particularly high in patients who cannot feed themselves and require the assistance from another person.  Lastly, financial burdens imposed by limited income are among the most important factors that contribute to undernutrition in the elderly.  Poverty is a key factor in determining inadequate nutritional status of older persons. 
     
    The next five scenarios, in table format provides a step wise approach to managing undernutrition in the elderly.3 David Lipschitz, developed this approach to use across all health care settings.  Quality nutrition care is a basic and important component to assess when servicing the elderly.  Recognizing and assessing the causes of undernutrition is an important aspect of routine geriatric care.   A team approach is the most effective way to assess and manage the multifaceted  problem of undernutrition.  The team consists of a (but not limited to) physician, nurse, dietitian, physical therapist and social worker.   Each member has their area of expertise to assess and make recommendations.  Treatment should be directed toward any identified underlying causes and ameliorating them.

    Scenario One
    1.  Identify and treat the cause
    2.  Weight Gain
    5.  Improved prognosis and quality of life


    Scenario Two
    1.  Identify and treat the cause
    2.  Despite therapy no increase in weight
    3.  NUTRITIONAL SUPPORT: Frequent small meals high in protein and fat, supplements as meal replacements or late night snacks.
         PHYSICAL THERAPY:  Exercise
         OCCUPATIONAL THERAPY
         ? ANABOLIC AGENTS
     
    4.  Weight Gain
    5.  Improved prognosis and quality of life

     
    Scenario Three
    1.  Identify and treat the cause
    2.  No cause identified or no treatable condition
    3.  NUTRITIONAL SUPPORT: Frequent small meals high in protein and fat, supplements as meal replacements or late night snacks.
         PHYSICAL THERAPY:  Exercise
         OCCUPATIONAL THERAPY
          ? ANABOLIC AGENTS
    4.  Weight Gain
    5.  Improved prognosis and quality of life


    Scenario Four
    1.  Identify and treat the cause
    2.  Despite therapy no increase in weight, no cause identified, or no treatable condition
    3.  NUTRITIONAL SUPPORT: Frequent small meals high in protein and fat, supplements as meal replacements or late night snacks.
         PHYSICAL THERAPY:  Exercise
         OCCUPATIONAL THERAPY
          ? ANABOLIC AGENTS
    4.  No weight gain
    5.  Consider Enteral Hyperalimentaion
    6.  Weight Gain and improved prognosis and quality of life

     
    Scenario Five
    1.  Identify and treat the cause
    2.  Despite therapy no increase in weight, no cause identified, or no treatable condition
    3.  NUTRITIONAL SUPPORT: Frequent small meals high in protein and fat, supplements as meal replacements or late night snacks.
         PHYSICAL THERAPY:  Exercise
         OCCUPATIONAL THERAPY
          ? ANABOLIC AGENTS
    4.  No weight gain
    5.  Poor prognosis
    6.  Assess for Hospice

    It is important to note with a poor prognosis, focus should be shifted towards reviewing the patient's wishes and advanced directives, which may lead to a decision for palliative care.  This is a tremendous decision, with an impact that cannot be underestimated.  Once again a team approach is a very holistic way to manage this situation.  The team strives to meet the comprehensive needs of both the family and the patient.

    Elderly patients with several nutritional risk factors are at higher risk for many complications and poor prognosis.  Table 4 shows the nutritional risk factors for short-term mortality.  At this time data is equivocal whether improvement in these risk factors improves prognosis. 
     
    Table 4                    Nutritional Risk For Short Term Mortality

    AlbuminLess than or equal to 2.5
    CholesterolLess than or equal to 120 (Cholesterol level of less than 80 means a 100% risk of mortality within 6 months)
    Weight lossUnintentional weight loss of 5% in one month and 10% over 6 months

     
     In conclusion, nutrition should be assessed with each visit to the doctor.  Undernutrition should be a suspect when there is unintentional weight loss of greater than 10% in six months or 5% in one month, depression and or functional decline.  The underlying causes should be addressed and treated.  If there is a poor prognosis, advanced directives should be reviewed palliative care should be offered as a treatment option.
     
     

     
     
     
    1 Dietary Reference Intakes (DRI).  Food and Nutrition Board, The Institute of Medicine, National Academies of Sciences.  March 2001.
    2 Morley, John., The Nutritional Risk Screening SCALES. J Am Geriatrics Soc. 1991; 39:1139-1140.
    3 Lipschitz,D.A,. Nutrition, in Geriatric Medicine, Ed. Cassell, Cohen, Larson, Meier, Resnick, Robenstien, Sorensen.  Springer Publishing Company, New York 1997.
     
    References:
     
    Singh,M.A.F.,Rosenberg,I.H., Nutrition and Aging, in Principles of Geriatric Medicine and Gerontology, Ed. Hazzard, Blass, Ettenger, Holter, Ouslander.  McGraw Hill, New York, 1999.
     
    Fogt, EJ., Bell, SJ., BlackBurn, GL., Nutrition Assessment of the Elderly in Geriatric Nutrition A Comprehensive Review.  Second Edition.  Ed. J. Morley, Z. Glick, L. Rubenstein.  Raven Press New York. 1995