Promoting Nutrition Wellness of Older Adults

The Gastrointestinal System

-Age-related changes affects all organs of the GI system but the impact on nutrition is minimal

-Most GI problems and nutrition issues are caused to a larger degree by risk factors that affects most older adults

-The age-related changes in the GI have minimal negative affects on consumption and absorption of nutrients and waste excretion

Age-related changes in olfactory function

-Smell: Facilitated by sensory cells in nose and olfactory cortex in the brain

-Ossification and closure of the olfactory foramina→ The small holes get smaller and close, the neurons can’t transmit to the olfactory bulb

-Decreased regeneration of olfactory receptor neurons

-Decreased olfactory receptors

-Degenerative processes occurring in the brain

Prevalence of olfaction impairment

-2% of <65 years old

-about 50% of 65-80 year olds

-75% of >80 year olds

Age-related changes in Gustatory Function

-Taste: facilitated by sensory receptors in the mouth and gustatory cortex

-Decreased receptors in taste buds (tongue, palate, tonsils)

-Decreased differentiation of sensory receptors

-Decreased ability to detect salty/sour/bitter tastes, but sensation for sweet is maintained

-Gustatory impairment is less prevalent than olfactory impairment

-What is perceived as a taste deficit may be a primary defect in olfaction

-Regional gustatory deficits more common but most older adults are not aware of them

Risk Factors that Affect Olfactory and Gustatory Function

-Neurological: Alzheimer’s disease, Epilepsy, Head trauma, Multiple sclerosis, Parkinson’s disease, Tumors and lesions

-Endocrine: Adrenal cortical insufficiency, Congenital adrenal hyperplasia, DM, Cushing’s syndrome

-Local conditions: Allergic rhinitis, Bronchial asthma, Sinusitis and polyposis, Xerostomic conditions(Sjogren’s syndrome)

-Viral infections: Acute viral hepatitis, Influenza

-Drugs: Antihistamines, Salicylates, Hypoglycemics, Antiparkinson drugs, Diuretics, Psychoactive drugs

Oral Cavity: Age-related changes

-Teeth fracture more easily

-Flattening of chewing cusps

-Xerostomia→ decreased saliva, dry mouth

-Presbyphagia : slowed swallowing; less severe version of dysphasia

Oral Cavity: Risk Factors

-Periodontal disease→ tooth loss

-Social: poverty, no transit/insurance

-Functional: ADL dependence, dementia

-Medications can cause gum hyperplasia

Xerostomia affects nutrition and gastrointestinal function

-Altered chewing and swallowing

-Difficulty talking

-Dry, cracked lips

-Burning sensation in mouth and lips

-Uncomfortable dryness of mucous membrane

-Decreased sensation of taste

-Increased risk for dental caries and plaque buildup

-Gingivitis and periodontitis

Other Age-related changes in the GI system

-Decreased taste sensation

-Esophagus more dilated

-Reduced saliva and salivary ptyalin

-Liver smaller in size

-Reduced intestinal blood flow

-Decreased esophageal motility

-Atrophy of gastric mucosa

-Decreased stomach motility, hunger contractions, and emptying time

-Less production of hydrochloric acid, pepsin, lipase, and pancreatic enzymes

-Fewer cells on absorbing surface of intestines

-Slower peristalsis

-In combination with risk factors, these changes affect safety, eating patterns, digestion, and nutritional requirements

Age-Related Changes in Nutritional Requirements

-Calories: need less quantity, better quality→ Increased nutritional density; Avoid ETOH-empty calories, Decreased carbohydrates (130g/day)

-Protein: minimum daily intake of 1.0 to 1.6g/kg of body weight; encourage higher protein intake

-Maintain fiber (25 to 38g/day) and abundant fruit & vegetables intake; prevents constipation

-Healthy oils: not more than 10% to 30% of daily caloric intake: increased unsaturated or polyunsaturated from nuts, seeds, avocado, olive and canola oil, Decreased saturated fat→ processed food, whole milk, butter, cheese

-Water: hydration essential for all physiologic functions; decreased thirst perception→ get 2.7-3.7 liters; should not decrease water intake to limit urinary incontinence

-Balanced diet to have decreased calories, protein to maintain muscle mass, fiber, low sodium, low saturated fats, adequate variety of whole grains, fruits and vegetables

Mediterranean Style Diet

-Gold standard for healthy aging and increased life expectancy, beneficial effects:

-Greater likelihood of healthy aging and improved longevity

-Improved health-related quality of life in physical and mental functioning

-Protection from cardiovascular disease

-Improved blood pressure control

-Independent predictor of healthy lung function

-Decreased risk of developing cognitive impairment

-Decreased risk of developing depression

Risk Factors Affecting Eating Pattern, Digestion, and Nutrition

-Psychosocial factors: Loneliness, stress, anxiety, memory issues, depression

-Environmental factors: Long-term care, community, access, poverty

-Behavioral factors: Myths and misunderstandings; low roughage; laxative overuse

-Functional impairments: Difficulty procuring, preparing, enjoying food; dysphagia

-Oral care conditions: Edentulous; poor oral hygiene

-Lifestyle factors: Alcohol use; smoking

-At risk for malnutrition at long-term care facilities along with significant weight loss; may not like the food offered, doesn't meet religious or cultural requirements 

Potential Medication effects on Digestion and Nutrition: Anorexia

-Digoxin

-Theophylline

-Fluoxetine

-Antihistamines

Potential Medication effects on Digestion and Nutrition: Constipation

-Anticholinergics

-Narcotics

-Calcium Channel Blockers

-Iron-Aluminum-

-Calcium-based antiacids

Potential Medication effects on Digestion and Nutrition: Diarrhea

-Cimetidine

-Laxatives

-Antibiotics

-Cardiovascular durgs

-Cholinesterase inhibitors

Potential Medication effects on Digestion and Nutrition: Gastric Irritation

-Non-steroidal anti-inflammatory drugs (NSAIDs)

-Aspirin

-Corticosteroids

Potential Medication effects on Digestion and Nutrition: Gum hyperplasia

-Phenytoin

-Nifedipine

-Diltiazem

-Cyclosporine

Potential Medication effects on Digestion and Nutrition: Early Satiety

-Bulk-forming agents when taken before meals

-Anticholinergics

Potential Medication effects on Digestion and Nutrition: Dysphagia

-Potassium supplements

-NSAIDs

-Bisphosphonates

-Prednisone

Potential Medication effects on Digestion and Nutrition: Xerostomia

-Anticholinergics

-Antihistamines

-Diuretics

-Muscle relaxant agents

-Opioids

-Psychoactive drugs

Overage Drinking

-Is it appropriate for individuals over the age of 65 to drink?

-No more than 7 drinks per week, no more than 1-2 drinks per day for other adults without any chronic conditions and not taking any medications

Risk Factors Affecting Nutrition: Alcohol Abuse

Age-related changes

-Decreased total body water and increased adipose tissue

-Decreased alcohol metabolism in the GI tract

-Increased sensitivity and decreased tolerance to alcohol

Functional consequences

-Risk for falls, self neglect and decreased cognitive capacity

-Decline in visual, auditory, and perceptual capacities

-Adverse drug reactions: interacts with at least 50% of prescription drugs

-Complications with chronic medical or psychiatric disorders

Dysphagia

-Difficulty during any phase of swallowing process

-Increased prevalence in acute (44-47%) and long term care (60%)

-Risk factor for aspiration due to decreased ability to cough and gag

-Interventions: HOB up, thicken fluids

S/S of dysphagia

-Drooling

-coughing during meals

-voice changes following meals

-gurgling sounds in the throat

-upper respiratory tract infection

-Wet lung sounds

-packing food in the cheeks

S/S of aspiration pneumonia

-Delirium

-Fever

-Chills

-Elevated respiratory rate

-Pleuritic chest pain

-Respiratory crackles

Dehydration: Age-related changes

-Diminished thirst perception

-Decreased renal function

-Altered body composition

Dehydration: Risk Factors

-Older age

-Polypharmacy

-Insufficient fluid intake

-Acute and chronic conditions

Dehydration: Functional consequences

-Falls

-Constipation

-Orthostatic hypotension

-Delayed wound healing

-Altered mental status

Constipation

-Decreased frequency of defecation with difficult or incomplete passage of hard, dry stool

Caused by risk factors→ not age-related changes alone

-Decreased activity, exercise and muscle strength

-Inadequate fiber and fluid intake

-Medications: calcium channel blockers

-GI disorders: ileus, diverticular disease, IBS, strictures

-Muscle/nerve disorders: Parkinson’s disease, systemic sclerosis

Prevention and Intervention for Constipation: Nutrition and lifestyles

-High-fiber diet; 2-3 L fluid daily (reduce coffee and alcohol)

-Encourage physical activity/ ambulate as appropriate

-Manage underlying conditions and medications

Prevention and Intervention for Constipation: Toileting and bowel routine

-Toilet at the same time daily; about 30 minutes after a meal (especially morning)

-Encourage responding to natural urge; ensure privacy

-Proper positioning; elevated toilet seat if needed

Prevention and Intervention for Constipation: Pharmacologic support

-Stool softeners

-Bilk-forming agents

-Mild stimulants

-Used judiciously

Laxatives and Stool Softeners

-Take with full glass of water

-Bisacodyl (Dulcolax), stimulant laxative: Mild cramps, rash, nausea, diarrhea

-Mineral Oil, Lubricant: on BEERS List, potential for aspiration, difficulty breathing, persistent cough, diminished absorption of vitamin A, D, E, and K

-Docusate(Colace), Stool softener: Softens fecal mass/Contraindicated in atonic bowel

-Magnesium hydroxide(Milk of Magnesia), Osmotic laxative: Draw water from plasma by osmosis increasing fecal mass/ Na+ salts can exacerbate heart failure

-Psyllium (metamucil), Bulk forming laxative: Absorbs water/stimulates peristalsis/Possible obstruction of GI, can cause severe constipation if daily recommended water is not drunk, do not take any drugs within 2 hours before or 2 hours after taking

Nursing Assessment of Nutrition

-Interviewing about digestion and nutrition

-Observing cues to digestion and nutrition

-Using physical assessment and laboratory information (pre-albumin, transferrin)

Nutrition assessment tools

-Short Nutrition Assessment Questionnaire

-Simplified nutrition appetite questionnaire

-The mini nutritional assessment(MNA) tool

Using The mini nutritional assessment(MNA) tool

-Proper measurement of height and weight and a detailed weight history

-Height should always be directly measured and never recorded based on self-report

-If BMI can not be calculated, use the calf circumference

-Calorie count or dietary recall to quantify the type and amount of nutrients ingested

Malnutrition in Older Adults

-Both under and over weight at risk for malnutrition

-Protein-energy malnutrition: calories/protein too low

-Common in hospitalized and institutionalized

-5% to 12% of community-living older adults

-Up to 55% of hospitalized elderly

-52% to 85% of older adults living in long-term care facilities

-Symptoms: weakness, lethargy, weight loss, muscle/fat loss

Unintentional Weight loss in older adults

-Weight loss of >5% within 1 month or 10% in 6 months

Functional consequences

-In-hospital complications

-Decreased ADLs and physical function

-Decreased quality of life

Nursing interventions

-Goal: Achieving/maintaining body weight within 110% of ideal body weight for the individual

-Address underlying causes (risk factors, functional, pathological, cognitive)

-Evaluate medications

-Frequent small meals if early satiety; attention to nutrients

-Utilize resources to promote food access: transit, meals on wheels

-Monitor periodontal disease, oral hygiene, dentures

-Monitor ability to chew and swallow, use of thickened liquids

-Sit up x30 minutes-1 hour post meal to compensate for slow swallowing

-Nutritional supplement prn for at risk individuals

-Referral (If needed): interdisciplinary consultations can be helpful

S/S of malnutrition

-Weight loss

-Lack of subcutaneous fat

-Diminished size and strength of muscle

-Skin that is dry, rough, and thin

-Abnormal pulse or blood pressure

-Edema, especially in the lower face and lower extemities

-Hair that is dry, brittle, dull, thin, or sparse

-Dey and dull-looking eyes

-Listlessness, apathy, and depressed mood

-Difficulty walking or maintaining balance

Laboratory tests for malnutrition

-Hemoglobin and hematocrit (anemia)

-Lymphocytopenia

-Serum 25-hydroxyvitamin

-Serum albumin

-Cholesterol

-Total iron-binding capacity